Jun 2, 2018

Full text of "New York medical journal."

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W YORK MEDICAL JOURNAL

INCORPORATING THE

PHILADELPHIA MEDICAL JOURNAL

AND THE

MEDICAL NEWS

SEMIMONTHLY REVIEW OF MEDICINE

AND SURGERY

VOLUME cxin.

JANUARY TO JUNE, 1921. INCLUSIVE

NEW YORK
A. R. ELLIOTT PUBLISHING CO
1921

COPYRIGHT. 1921, BY A. R. ELLIOTT PUBLISHING COMPANY.

LIST OF CONTRIBUTORS TO VOLUME CXIII.

Those whose names are marked with an asterisk have contributed editorial articles.

Aaron, Charles D., M. D., Detroit,
Mich.

ACATSTON, S. A., M. D.

Apfel, H., M. D., Brooklyn.

♦Arrowsmith, Hubert, M. D., F. A.
C. S., Brooklyn, N. Y.

AsHBY, Winifred, B. S., M. S., Roches-
ter, Minn.

AsNis, Eugene J., M. D., Philadelphia.
Atwell, Wayne J., Buffalo, N. Y.

Babcock, W. Wayne, M. D., F. A.

C. S.. Philadelphia.
Bailey, John H., M. D., Brooklyn,

N. Y.

Ballenger, Edgar G., M. D.. F. A. C. S.,
Atlanta, Ga.

Barker, Lewellys F., M. D., Baltimore.

Barker, Walter C.. M. D., Philadelphia.

Barnes. George Edward, B. A., M. D.,
Herkimer, N. Y.

Behrend, Moses, M. D., Philadelphia.

Besse, p. M., M. D., Geneva, Switzer-
land.

BicK, H., M. D.

Blair, Thomas S.. M. D.. Harrisburg,
Pa.

Blau, Arthur I., M. D.

Blumgarten, a. S., M. D., F. A. C. P.

Boas, Ernest P., M. D.

♦Bolduan. Charles F., M. D., Wash-
ington, D. C.

Bram, Israel, M. D., Philadelphia.

Brav, Aaron. M. D.. Philadelphia.

Briggs, L. Vernon, M. D., Boston,
Alass.

*Brink, Louise, A. B.

Broadwin, I. T., M. D.

Buchanan, J. Arthur, M. D., Roches-
ter, Minn.

Buckley, Albert C, Philadelphia.

Bulkley, L. Duncan, M. D.

Bullard, E. a.. M. D., F. a. C. S.

Burns, Frank, M. D., Cincinnati, Ohio.

Burns, Joseph P., M. D., Philadelphia.

Putsch, J. L., M. D., Ph. D., Roches-
ter, Minn.

Butts, Donald C. A., M. D., Philadel-
phia.

Callison, James G., M. D.
Carmody, Thomas Edward, M. D., Den-
ver, Colo.
Cecil, Russell L., M. D.
Clark, L. Pierce, M. D.
*Clouti ng, Ch,\rles a., AI. D., London.
Cohen, Harry, M. D.
Cohen, Samuel, M. D., Philadelphia.

Coon, C. E., M. D., F. A. C. S., Syra-
cuse, N. Y.

Crane, Claude G., ■ M. D., Brooklyn,
N. Y.

Crile, George W., M. D., F. A. C. S.,
Cleveland, Ohio.

*Cumston, Charles Greene, M. D.,
Geneva, Switzerland.

Cyriax, Edgar F., M. D. (Edin.), Lon-
don.

Deaver, John B., M. D., Philadelphia.
De Brun' Harry Schultz, M. D.
Dewess, a. M., Philadelphia.
♦Donnelly, William Henry, M. D.,

Brooklyn, N. Y.
Drueck, Charles J., M. D., Chicago.

Eidelsberg, Joseph, M. D.
Einhorn, Max, M. D.
Eising, Eugene H., A. M., M. D.
Elder, Omar F., M. D., Atlanta, Ga.
*Elliott, George, M. D., Toronto.
Ellison, Everett M., A. M., M. D.,

Washington, D. C.
Ezickson, William J., A. B., M. D.,

Philadelphia.

Faught, Francis Ashley, M. D., Phila-
delphia.

Finklepearl, Henry, M. D

*Foster, Matthias Lanckton, M. D.,
New Rochelle, N. Y,

Fowler, Robert H„ M. D.

Frankel, Bernard, M. D.

Frantz, Morris H., M. D.

Friedman, G. A., M. D.

Friedman, Joseph, M. D., Brooklyn.

Friedman, Joseph H., M. D.

Freudenthal, Wolff, M. D.

Galland, Walter L, A. B., M. D.

Gardner, James A., M. D., F. A. C. S.,
Buffalo, N. Y.

Garretson, William V. P., M. D.

Geyser, Albert C, M. D.

Gies, William J., M. D., D. Sc.

Gilbride, John J., A. M., M. D., Phila-
delphia.

GoETSCH, Emil, M. D., F. A. C. S.,

Brooklyn.
Goldman, Harry', M. D.
Goldstein, Hyman L, M. D., Camden,

N. J,

Gordon, Alfred, M. D., Philadelphia.
Gordon, Murray B., M. D., F. A. C. P.,
Brooklyn.

Goutzait, p., AI. D., Geneva. Switzer-
land.

Grai), Herman, M. D.
Graham-Mulhall, Sara, M. D.
Greenfield, Arthur D.
Greenfield, Samuel D., M. D., Brook-
lyn.

Haines, Wilbur H., B. S., M. D., Phila-
delphia.

Hallock, Daviu H., a. M., M. D.,

Southampton, N. Y.
Hamilton, James A., Ph. D.
Hammer, A. Wiese, M. D., Philadelphia.
High MAN, Walter James, M. D.
Hirshfeld, Samuel, M. D.
Hodskins, Morgan B., M. D., Palmer,

Mass.

Hoxie, George Howard, A. M., M. D.,

Kansas City, Mo.
Huhner, Max, M. D.
Husik, J. A., A. B.. M. D., Brooklyn.
Hyslop, George H., M. D.

Iglauer, Samuel, B. S., M. D., Cincin-
nati, Ohio.
Illoway, H., M. D.
Imperatori. Charles J., M. D.

Jackson, Chevalier, M. D., Philadel-
phia.

Jacoby, Adolph, M. D.
*Jelliffe, Smith Ely, A. M., M. D.,
Ph. D.

Kahn, Max, M. D.
Kaplan, David M., M. D.
Keller, Henry, M. D.
*Kellogg, Elenore.
Kelly, Howard A., M. D., Baltimore.
Kempf, Edward J., M. D.
Kennedy, J. W., M. D., F. A. C. S.
*Kerbv, Ernest F., M. D.
*KiNG, Douglas, M. D.
*Knopf, S. Adolphus, M. D.
Knowlton, Frank P., AI. D., Syracuse.
N. Y.

KouiNDjY, Pierre, AI. D., Paris, France.

Landsman, Arthur A., AI. D.
Lapenta, Vincent Anthony, M. D..

Indianapolis, Ind.
Lazarus, David, M. D.
Levy, Louis Henry, AI. S-, AI. D., New

Haven, Conn.
Levy, Moise D., AI. D.. Galveston,

Texas.

Levyn, LeSter, AI. D., Buffalo, N. Y.
Lewinski-Corwin. E. H., Ph. D.
*LiEB, Charles, M. D.
Limerick, O. Victor, AI. D.
LiNTZ, Joseph, A. M., AI. D.

LirsiiLTZ, Uknjamin, M. D., I'liiladcl-
phia.

LissER, Hans, M. D., San Francisco.
LowsLEV, Oswald Swinney, A. B.,

M. D.. F. A. C. S.
LuTTiNGER, Paul, M. D.
Lydston, G. Frank, M. D., Chicago.
Lynch, Robert C, M. D., New Orleans,

La.

McCaskey, Donald, M. D.

McNuLTY, John J., M. D.

Maiiukkn, Russell F., M. D.

Marshall, C. J., Philadelphia.

Martin, Sergeant Price, M. L)., Buf-
falo, N. Y.

Meding, C. B., M. D.

Melman, Ralph J., M. D., Philadelphia

Melville, Stanley, M. D., London.

Menninger, Karl A., M. S., M. D.,
Topeka, Kansas.

Meyer, William H., M. D.

Miller, Edwin B., M. D., Philadelphia.

Miller, George L, M. D., Brooklyn.

Miller, Joseph W., M. D.

Mills, H. Brooker, M. D., F. A. C. P.,
Philadelphia.

Minton, Henry M., M. D., Philadelphia.

Morley, W. H., M. D., Pontiac, Mich.

Morris, M. Ford, Jr., M. D., Atlanta.
Ga.

Mosher, Eliza M., M. D., Brooklyn,
N. Y.

Murphy, John W., A. M., M. D., Cin-
cinnati, Ohio.

Mutch, Jane, B. A., London.

Mutch, N., M. A., M. D., F. R. C. P.,
London.

Neuhof, Harold, M. D.
Neumann, William, M.^D., Brooklyn.
Niles, Walter L., M. D.
Norman, N. Philip, M. D.
Northrop, Herbert L., M. D., F. A.
C. S., Philadelphia. .

O'Day, J. Christopher, M. D., F. A.

C. S., Honolulu, Hawaii.
Osborne, Oliver T., M. D., New Haven,

Conn.

Owen, Hubley R., M. D., Philadelphia.

Pancoast, Henry K., M. D., Philadel-
phia.

Patterson, Klli:n J., M. D., F. A. C. S.,

Pittsburgh, Pa.
Pkeiffer, William, M. D., F. A. C. S.,

Brooklyn.
♦I'liELPs, Edith B.
Porter, William Henry, M. D.
Pottenger, F. M., M. D., Monrovia, Cal.
Prentice, Alfred C. M. D.
Pritchard, H. B., M. D., Syracuse,

N. Y.

Pyle, Walter L., M. D., Philadelphia.

Reed, Charles A. L., M. D., Cincinnati,
Ohio.

Reede,- Edward Hiram, M. D., Washing-
ton, D. C.

Renaud, George L., M. D., Detroit,
Mich.

Riddell, Hon. William Renwick,

LL. D., Toronto, Canada.
Ridpath, Robert F., M. D., Philadelphia.
Roberts, John B., M. D., Philadelphia.
Rodman, Harry, M. D.
♦Rogers, James F., M. D., New Haven,

Conn.

Rose, Robert Hugh, M. D.

Rosenberger, Randle C, M. D., Phila-
delphia.

Rosenbluth, M., M. D.

Rosenheck, Charles. M. D.

Rout, Ettie A. (Mrs. Hornibrook),
London, England.

Rubenstone, a. L, M. D., Philadelphia.

*Rucker, W. C, M. D., United States
Public Health Service, Canal Zone.

RuTZ, Anthony A., M. D., Brooklyn,
N. Y.

*Sajous. Charles E. de M., LL. D.,
M. D., Sc. D.; Philadelphia.

♦Sajous. Louis T. de M., B. S.. M. D.,
Philadelphia.

Sanders, A. S., M. D.

Saphir, J. F., M. D.

Satterthwaite, Thomas E., M. D.

*Scarlett, Rufus B., M. D., Trenton,
N. J.

ScHROEDER, THEODORE, CoS Cob, CouU.

Sc hwartz, Louis H., A. B., M. D.
Shapiro, Isidor F., M. D.
Sheehan, J. Eastman, M. D.
Shuman, John W., M. D.. F. A. C P.,
Sioux City, la.

Shltmway, Edward A., M. D., Phila-
delphia.

SiEGEL, Alvin E., M D., Philadelphia.
Smith, Ethan H., M. D., San Fran-
cisco.

SoLis-CoHFX, Myer, a. B., M. D., Phila-
delphia.

Spencer, Willi a. m H., M-. D., Philadel-
phia.

*STEINBUf;LER, WiLLIAM F. C, M. D.

Stevens, J. Thompson, M. D., Mont-

clair, N. J.
Stivelman, B., M. D., Bedford Hills,

N. Y.

Strachstein, a., M. D.
*Stragnell, Gregory, M. D.
Strauss, Spencer G., A. B., M. D.

Takeuchi, Kumpei, M. D., Toyko.

Taylor, K. P. A., A. B., M. D., Phila-
delphia.

Tenner, Arthur S., M. D.

Thomson, J. Oscar, M. D.. Canton,
China.

Tiltox, Benjamin T., M. D.

Tim me, Walter, M. D.

TousEY, Sinclair, M. D.

TuTTLE, Homer, M. D., Ithaca, N. Y.

Van Hook, Weller, A. B., M. D., Chi-
cago.

*Vedin, Augusta, M. D.

*Warburton, Gladys Bagot.
*Waterson, Davina.
Watson, W. R., M. D., Philadelphia.
Wells, Walter A., M. D., Washington,
D. C.

Wheelon, Homer, M. D., St. Louis, Mo.
*Whitford, William, Chicago.
♦Williamson, Jefferson.
Wishart, D. J. Gibb, M. D., Toronto.

Canada.
Witherbee, W. D., M. D.

*W0LBARST, AbR. L., M. D.

Wright, Jonathan, M. D., Pleisant-

ville, N. Y.
WuRTZ, Walter J. M., M. D., Buffalo.

N. Y.

Young, Anne, M. D., Dr. P. H.,
D. T. M., University, Alabama.

ZiGLER, M., M. D.

New York Medical Journal

INCORPORATING THE

Philadelphia Medical Journal the Medical News

A Weekly Revieiu of Medicine, Established 18Jt3.

Vol.. CXIII, No. 1. NEW YORK. SATURDAY, JANUARY 1, 1921. Whole No. 2196.

Original Communications

OPERATION FOR RENAL CALCULI.

By Howard A. Kelly, M. D.,
Baltimore, Md.

Within the past forty years the surgical pro-
fession has run a gamut of changes in the variety
of operations for stone in the kidney and the renal
pelvis. It is my desire here to present what I
consider to be the simplest and best procedure and
one which I hope approximates a final solution of
this important question in the commoner cases.
Back of the seventies of the last century kidney
operations were extremely rare, and however excru-
ciating the pain the patient might suffer in his loin,
coupled as it might be with hemorrhages and pyuria,
his treatment was symptomatic and sedative. How
well I remember the course of just such a case in
the person of one' of my most intimate boy friends,
handled throughout its course by the late distin-
guished surgeon, my professor, D. Hayes Agnew.
With growing boldness in surgery following G.
Simon's initiative in his elaborate experimental work
on the extirpation of the kidney (1872), and with
the security given by antisepsis, the next step natur-
ally was the exposure and opening of the kidney,
often literally like an oyster, from stem to stem,
hunting for the stone which was too often elusive.
I had such a case in one of my closest friends.
He suffered for a long time from hematuria and
sudden attacks of intense posterior lumbar pain ;
often when driving his buggy through the streets
of a distant large city at night, when the pain struck
him he would double up and fall to the floor until
it passed. William Osier, who knew him, suggested
it might only prove to be a focal nephritis, but I felt
more confident of stone. According to promise I
opened his kidney from end to end, and found —
nothing. He recovered from this and was relieved
of his pains, but he died several years later in a
uremic convulsion following a surgical operation
on the axillary glands for a gas bacillus infection
contracted in an operation on an infected arm.

Following this came the era of \some more intel-
ligently determined and directed operations, due
to the introduction of the waxed tip catheter in the
nineties, an intelligence soon augmented by the
gradually perfected x ray diagnosis, which not only
defined the disease, like the waxed catheter, but also
located the position, and often the number and size
of the stones. With this greater precision in diag-
nosis the incision into the kidney naturally was often

more limited in its extent, although still appallingly
extensive, and the damage done was still consider-
able, and the hemorrhage sometimes threatening.
Then came an era of pyelotomies for pelvic stones,
particularly encouraged by an avascular posterior
incision between the vascular watersheds of the
kidney, when the cut had to be extended up into
the kidney, thus lessening the hemorrhage.

I exclude from consideration massive and ex-
tensively branching calculi, where there is nothing
to be done but to excise the kidney, when its func-
tion is wholly in abeyance, or at most to incise it
from end to end in the effort to remove the calculus
without extensive tearing of the tissues.

My own active personal association with, and
interest in, this field, has passed through several of
the stages cited above. Soon after discovering the
method of direct aerocystoscopic examinations, with
the pelvis elevated, I waxtipped my bougies and
so was often able in favorable stone cases to get
a scratch mark on the wax, and so to make an
immediate diagnosis at the very first examination,
of a stone in the ureter or kidney. A great advan-
tage of this method is that it is carried out on the
examining table and does not require any prepara-
tion of the patient, or the delays incident to a
reference to an x ray expert often in another clinic.
With due care the wax tip method is both certain
and satisfactory, and I still use it as a routine, while
using the x ray also.

In my effort to save the kidney from injury, I
then began to resort extensively to pyelotomy, draw-
ing especial attention to the necessity of preserving
the fibrous sheath investing the pelvis of the kidney,
described by Dr. William J. Mayo and myself.
This sheath also investing ureter and bladder, is of
particular value in both of these latter situations as
a binder in closing incised wounds.

Lastly I worked out the operation which I am
about to describe ; at first blush an apparent return
to our former cruder plan of splitting open the
kidney, but differing toto coelo in being done with
a full understanding of the exact status of the or-
gan, as to functional value, site and number of stones
as well as their size, and with a definite technic
adapted to the particular case. This procedure is
accompanied with a minimal and usually insig-
nificant trauma, as yet with no serious hemorrhage;'
it is rapid in its execution, and usually avoids any
urinary leakage, such as was not infrequently under
older methods. On account of its rapidity and the

Copyright, 1921, by A. R.

Elliott Publishing Company.

2

KELLY: RENAL CALCULI.

[New York
Medical Journal.

slight damage done, I, am in the habit of calHng
it at the operating table my "sneaking operation."
Let me describe it :

A patient comes with a pyuria or a hematuria,
or both, and often with a one sided pain. The
mixed urine is taken by catheter from the bladder,
and if a woman, the ves-
ical ends of the ureters
are palpated carefully
through the vagina. She
is then cystoscoped in
the knee chest posture,
and the suspicious side
catheterized with a
waxed tip catheter
(Fig. 1 A). The urine
flowing directly from
that side is collected in
a test tube, while the
urine discharging from
the other side is collected
transvesically by an or-
dinary vesical catheter
in a test tube. At the
same time the functions
of the kidneys are esti-
mated by examining the
separated urines and by
injecting phenolsulphone-
phthalein. After one or
two hours, or sometimes
after a few minutes, if
the differentiation of
the urines is sufficiently
marked to the naked eye,
the renal catheter is removed and the waxed tip is
examined with a lens for scratch marks (Fig. IB).
An X ray picture then taken also shows the calculus
or calculi either in the renal pelvis or up in one or
more of the calices (Fig. 2).

Fig. 1. — A, a ureteral catheter
from 1 J4 to 2 mm. in diameter
— the end coated with wax. B,
the same catheter after it has
been gouged or scratched by com-
ing into contact with the stone
in the pelvis of the kidney. Note
that the wax covered end is
sometimes hammered down as
shown here.

THE OPERATION.

The best incision is through the posterior superior
lumbar triangle. In many cases I pull the tissues
widely open with my two hands by a blunt dissec-
tion, thus securing enough room to introduce four
or five fingers, the whole hand. After breaking
through Gerota's capsules by simple traction with
forceps on the perirenal fat it is often possible to
draw the entire kidney out onto the surface.
Whether it comes out in this way, or whether it
has to be detached by gentle manipulations on all
sides, separating it par-
ticularly in its upper
pole, in most cases, it is
displaced onto the loin
without the slightest
damage, and dealt with
there in the succeeding
stage. Often, however,
knowing exactly the
position of the stone, I
operate upon the kidney
in situ, and make a direct opening into its lower
pole, or again simply free and tilt down the upper
pole, so as to bring it within reach for the extraction
of the calculus. In either case, whether treated
in situ or outside, the operator gently palpates the
kidney between the thumb and fingers, including
the renal pelvis, to see whether the stone can be
felt and located. If it is found it can then be
thrust up toward the dorsum with the fingers to
facilitate the enucleation. If it is not so located,
then with the x ray plate before him as a guide the
next step is to take a fine needle about six cm. in
length, fastened in a cork, and to thrust this into

Fig. 3. — Contour of kidney,
needle mounted on cork thrust
into contact with stone, and left
there.

Fig. 2. — Shadowgraph of the stone in the pelvis of the left
kidney under an unusually long last rib.

Fig. 4. Fig. S.

Fig. 4.— Spatulate instrument neither blunt nor sharp thrust
through the dorsum of kidney after making a short incision in its
capsule, and brought in contact with stone, which in most in-
stances can be pushed up towards the cortex to meet the in-
strument.

Fig. S. — Scissors used occasionally to enlarge the opening when
necessary. A little blunt tearing in this way as a rule provokes
no marked hemorrhage. The scissors can be used very well to
replace the instrument (Fig. 4) entirely.

the kidney, where it is expected the stone will be
found. Once the needle touches the stone, it is
left (Fig. 3) in situ, while a small incision (averag-
ing about two cm. in length, but varying with the
size of the stone) is made through the renal cap-
sule. An instrument is then taken in hand (Fig. 4)
which is neither blunt nor sharp, and which can be

January 1. 1921.]

KELLY: RENAL CALCULI.

3

[0

pressed against the finger without cutting it. This
is driven through the renal substance down to the
stone. A narrow pair of forceps (Fig. 6) is then
inserted and the stone caught and extracted. If
the removal is clean and clear, and there is only a
mild infection, I close the wound entirely with one
or two mattress sutures (Fig. 7) ; as
^1 the bleeding is usually minimal, a
single catgut mattress suture may suf-
fice. The external abdominal wound
is then closed with a small drain.
Sometimes it is an advantage, if the
stone is a little large, to carry the scis-
sors into the pelvis until the stone is
touched, and on withdrawing to oi)en
them a little, thus enlarging the
opening in a blunt way ( Fig. 5 ) .
Such a procedure as I have just de-
tailed is splendidly adapted to a stone
which is out in one of the calices, and
not far distant from the cortex. I
have removed in this way, with almost
no damage at all, a stone from the
upper and lower poles of the same
kidney, first tilting up one end and
then the other. I also prefer this
operation for stone in the pelvis of the
kidney as well, pushing the stone up
toward the dorsum.

Case. — Let me illustrate my thesis
further and dwell on this important
matter by citing a concrete case, that
of Mrs. E. M., No. 8911, who came
to me February 10, 1920, with a diag-
nosis of left renal calculus, made by
a skillful consultant and a friend in Buffalo.
I took an x ray (Fig. 2) as confirmatory of
the diagnosis, and without detailing the vari-
ous differentiation tests and preliminary exam-
inations made, I proceeded with the operation. The
usual posterior mcision was made through the pos-
terior superior lumbar triangle, and the kidney
freed and delivered at the incision. Gentle palpa-
tion fore and aft showed the presence of the stone
in the renal pelvis. A fine cambric needle was then
inserted through the back of the kidney, avoiding
the vascular lines, and left in situ, touching the

stone. A little incision
was made through the
capsule, and the blunt
instrument shown (Fig.
3) pushed through the
kidney and through the
renal pelvis until it
touched the stone, when
both it and the needle
were withdrawn; and
the stone grasped with
the forceps (Fig. 4)
and lifted out. One
mattress suture was
placed through the kidney near the hilum with a
blunt flat curved semicircular needle and tied gently,
just tight enough to control the circulation in the
limited area near the pelvis. Two catgut sutures
were then placed in the wound, uniting the capsule

KiG. 6. — Nar-
r o «■ forceps
grasping and
removing stone.

Fig. 7. — Sutures placed to
control the hemorrhage and
unite the capsule. The outer-
most suture is often put in just
above the pelvis of the kidney
using rather fine catgut; a and
b close the upper parts of the
wound and the capsule.

of the kidney, and the kidney was restored to its
position back of the peritoneum, and the muscles
brought together with catgut, a small iodoform
drain being left in the lower part. Recovery was
rapid without any leakage, and she left the hospital
on March 1st. Frecjuently twelve to fourteen days

Fig. 8. — With the exception of a flat, blunt pointed needle these
are the few simple instruments used in locating the stone, open-
ing the dorsum of the kidney, and removing the stone; a, the fine
needle used to find the exact position of the stone; b, the spatulate
instrument neither blunt nor sharp which is plunged through into
the pelvis of the kidney; c, scissors sometimes used to enlarge the
opening a little; d, the stone forceps used for the removal of the
calculus when it is somewhat larger; narrow forceps used to extract
a small calculus.

are long enough for the convalescence. The sketches
used in the text were made to illustrate this case.
I prefer this operation even when the calculus is
in the pelvis of the kidney and easily accessible, in
almost all cases.

Renal Hematuria. — Edward A. Young (Sur-
gery, Gynecology and Obstetrics, November, 1920)
concludes that: 1. The cause of renal hematuria
can be demonstrated in all but a very small propor-
tion of cases. 2. Kidney bleeding of unknown
origin has been known to be enough to threaten life
and require nephrectomy. 3. A horseshoe kidney,
a slightly movable kidney, a varix of a renal papilla,
may exist without the possibility of positive pre-
operative diagnosis. 4. In a few instances the split
ftmction may show considerable damage on the
bleeding side and the pyelogram a considerable de-
viation from the normal, a combination which should
require exploration ; but these cases are very rare
and operation as a routine exploratory procedure in
cases of hematuria of unknown origin is unwise,
as there is no assurance that it will have any effect
on the progress of the bleeding. 5. In a fair num-
ber of these cases a later nephritis has been proved
to be the cause of trouble. 6. It is reasonable to
believe that in a majority of these cases there is an
early unrecognized nephritis or a prenephritic con-
dition which can be the cause of hematuria, and
that this condition may go on to a progressive dam-
age of the kidney.

4

TILTON: GALLSTONE DISEASE.

[New York
Medical Journal.

DANGERS TO LIFE ASSOCIATED WITH
GALLSTONE DISEASE AND
THEIR PREVENTION.

By Benjamin T. Tilton, M. D.,
New York.

Every individual with gallstones encounters cer-
tain definite dangers of a complication which may
change what, seems to be a simple, though painful,
local manifestation into a condition of affairs which
may prove fatal. This may happen during any
period of gallstone disease and, in fact, may be the
first occurrence which demonstrates unmistakably
to the patient or physician the fact that gallstones
are present. Indefinite digestive disturbances which
may be attributed to the stomach may be present
for many months, when out of a clear sky an acute
attack of cholecystitis or a sudden jaundice lays the
patient low. More frequently a patient suffers for
months or years from intermittent attacks of gall-
stones before one of these, dangerous emergencies
arrives.

There are four chief -dangers that may threaten
the life of a carrier of gallstones: 1. Acute suppu-
rative or gangrenous cholecystitis ; 2, cholangitis ;
3, malignant disease of the gallbladder, and, 4, opera-
tion in delayed cases.

Acute suppurative or gangrenous cholecystitis is
ushered in with excruciating pain in the right hypo-
chondrium, sometimes a chill, rising temperature,
and usually vomiting. The pain frequently radi-
ates to the right shoulder. Examination reveals
marked abdominal rigidity, a mass caused by the
distended gallbladder and adherent omentum, a very
high leucocyte and characteristically high polynu-
clear count. Jaundice is usually absent, but if
present may be caused by pressure of enlarged
glands on the common duct. The diagnosis should
be easily made.

Operation should not be delayed in the severer
types of cases. Sepsis, perforation of the distended
or gangrenous gallbladder may occur. Simple
drainage of the gallbladder is the operation of
choice in the severe cases, especially those that have
been delayed to the detriment of the patient's gen-
eral condition. Mortality from this complication of
gallstones is usually due to delay in operation or
to the attempt of a too radical operation. Cholecys-
tectomy gives a high mortality when performed
on a fat subject with a highly placed suppurating
or gangrenous gallbladder, especially if performed
after forty-eight hours.

Cholangitis usually implies that one or more gall-
stones have entered the common duct and caused
stoppage of the flow of bile with resulting infection.
The most characteristic symptom is jaundice. This
should always be regarded as a danger signal, as
the patient has entered a stage of the disease which
increases greatly the risk to life. Chills, intermittent
fever, sweats and prostration frequently accompany
the jaundice, and if allowed to persist may result
fatally. More frequently the^ obstruction is tem-
porarily relieved by the stone being passed or
dropping back, the bile flows again into the intestine,
and all the symptoms disappear. The choice of the
time for operation in these cases is a matter of

judgment on the part of the surgeon. Operation
is more hazardous at the height of the attack and
in the presence of jaundice, but if the symptoms
persist more than forty-eight hours and the patient's
general condition is growing worse from the absorp-
tion of septic bile, operation offers the best chances
and should not be further delayed. Here also the
simpler and shorter operation for drainage of the
gallbladder will meet the vital indications and save
the patient's life in cases where the patient would
succumb to the more complicated and prolonged
operation of choledochotomy and removal of the
stones in the common duct. If the patient is fortu-
nate enough to recover from the attack of cholan-
gitis under medical treatment he should not be
allowed to run the dangers of another such attack
and operation in the interval is the safest procedure.
At this time removal of the gallbladder with its
stones, and removal of the stones in the common
duct, followed by drainage of the latter by means
of a tube, are the procedures of choice. It cannot
be emphasized too strongly that one attack of jaun-
dice associated with stones indicates operation in
the absence of other factors that may contraindicate
operations in general.

Malignancy starting in the gallbladder is not a
rare complication of gallstones and is, of course, a
most serious one. Unfortunately, in most cases the
carcinoma is too far advanced when diagnosed to
admit of complete surgical removal. Metastases in
the liver are not amenable to surgery, and it is only
when the disease is localized in the wall of the gall-
bladder that surgery is successful. These are the
cases that are operated upon under the diagnosis of
chronic cholecystitis and in which the carcinoma is
found by accident before it has spread to the sub-
stance of the liver. Every chronic thickened gall-
bladder with stones has the possibility of a malig-
nant change, and hence should not be allowed to
remain. The appearance of jaundice in these cases
not associated with signs of obstruction of the com-
mon duct means involvement of the liver by the
metastatic growth ,and hence is a most unfavorable
sign. Operation in these cases is rarely successful.

The history given by patients with carcinoma of
the gallbladder is usually, one of repeated gallstone
attacks extending over a period of several years.
One is always struck by the pathos of the thought
that in these cases operation at the beginning would
have avoided the tragedy of a miserable death from
cancer of the gallbladder and liver starting from
the prolonged irritation of the stones which were
allowed to remain so many years in the gallbladder.

Operation in delayed cases of cholelithiasis is
often hazardous. This has already been pointed
out as true of the acute cases of suppuration, gan-
grene of the gallbladder, and obstruction of the
common duct associated with cholangitis. It is also
true of the chronic cases which are often allowed
to go on for fifteen or more years. Important
degenerative changes occur in the myocardium and
kidneys, which render the patient a poor operative
risk. Under these conditions operation must not
be undertaken hurriedly and without adequate
examination and preparation. If the blood pres-
sure is too low, the heart action irregular, or func-

January 1, 1921.]

LAPENTA: GALLBLADDER LESIONS.

5

tional tests of the kidneys insufficient, these must
be corrected before operation. But even with these
precautionary measures the operation is often
dangerous in these long delayed cases and certainly
much more so than in the early periods of the dis-
ease before degenerative changes have begun. It
must be borne in mind that delayed operations are
as a rule more difficult and prolonged owing to
more complicated pathology. One encounters firm
adhesions between the gallbladder and intestines or
omentum, possibly a communicating opening into
the intestine, marked thickening and contraction of
the gallbladder, all of which make the dissection
difficult and prolonged and add materially to the
risks incident to delayed operation. The contrast
between a cholecystectomy on an unthickened non-
adherent gallbladder and one on a sclerosed adherent
and deeply embedded one is most striking to t'^
surgeon and the onlooker both as regards the diffi-
culty of the technic as well as the valuable time
expended on the dissection. The separate exposure
and ligation of the cystic duct and artery have be-
come much more difficult and the subsequent danger
of secondary hemorrhage and leakage of bile from
sHpping of the ligatures are much increased. The
removal of the stones from the common duct and
ampulla of Vater and drainage of the duct add to
the operative risk and often call for the highest
degree of technic in order to be successfully per-
formed. All these dangers can be avoided by opera-
tion in the early stages of the disease before the
onset of complicating inflammatory changes and
migration of stones from the gallbladder into v the
ducts. The conclusion is unavoidable that early
operation in cholelithiasis is strongly indicated, and
that only in this way can the present high mortality
of this serious disease be lowered.

14 E.\ST P'iFTY-EIGHTH StrEET.

PATHOGENESIS AND PHYSIOPATH-
OLOGY OF GALLBLADDER AND
BILIARY TRACT LESIONS.
By Vincent Anthony Lapenta, M. D.,

Indianapolis, Ind.

The recent advancement in our knowledge of
focal infections in general has necessitated a revi-
sion of our conceptions of the pathogenesis of many
diseases, and incidentally has forced us to view
many disorders from a physiopathological view-
point, rather than from that of morbid anatomy
alone. This change in our viewpoint constitutes a
great step forward in itself, since this method
enables us to detect diseases in their incipiency, and
often, by our knowledge of the pathogenetic pro-
cess, we are enabled to formulate effective preven-
tive treatment.

Diseases of the gallbladder and biliary ducts
comprise a group of abdominal syndromes of com-
mon incidence. In fact, gallbladder aPffections are
second in occurrence only to lesions of the appendix.
Pathologists report the presence of gallbladder
lesions associated with' calculi in from five to seven
per cent, of all autopsy cases. European path-
ologists have reported even a larger percentage.

occurrence of gallbladder lesions in
relation to age and sex.

The incidence of gallbladder diseases increases
with age. It is far more common after the age
of thirty than at any preceding time in life, the
greatest number of occurrences taking place between
thirty-five and sixty years. While not very com-
mon, gallbladder lesions, especially of the acute
infectious type, are not rare in younger people and
even in children. Reid (1) has made a collective
study of acute cholecystitis in children, following
typhoid fever. We have ourselves observed this
complication in children. In our first series of 114
gallbladder cases, we had two cases of acute chole-
cystitis of probable hematogenous origin ; one in a
boy of eleven years and the other in a girl of
seven. Both of these patients had suffered sev-
eral attacks of tonsillitis. In the boy's case, no
bacteriological study was made of the bile and
gallbladder ; in the girl's case, presenting an acute
suppurative cholecystitis, a cholecystectomy was
performed, with biliary drainage secured through
a choledochostomy. Study of the common duct
bile, on several occasions, gave persistently negative
findings. The disease seemed to be confined en-
tirely to the gallbladder. The histopathological
study of the gallbladder wall showed the presence
of active inflammation, injection of vessels, round
cell infiltration, desquamation of the surface epi-
thelium, small necrotic foci, and, here and there,
small coagula of plastic lymph. Bqth in the tissues
and in the pus, it was possible to demonstrate a
short chain streptococcus. A study of the discharge
of the tonsillar crypts of the same individual re-
vealed the same organism. The patient was later
directed to have her tonsils removed.

Women are far more susceptible to gallbladder
diseases than men. Hubbard and Kimpton (2), in
a series of four hundred cases, found a ratio of
three to one in frequency. Jacobson (3) reports
the incidence of four to one in a series of cases
at the Peter Bent Brigham Hospital. Among the
predisposing factors, in a way accounting for this
greater frequency of gallbladder lesions in women,
may be mentioned their greater tendency to a
sedentary life, pregnancies with their concomitant
stress on hepatic function, and high blood choles-
terol content — a constant concomitant of gestation.

physiopathology" of gallbladder diseases.

Before we can hope to get a firm grasp of the
pathogenesis of these lesions, and even before we
can attempt to draw any instructive conclusions on
their surgical and medical treatment, we must
attempt to get a clear understanding of the physi-
ology of the biliary apparatus and develop from
this our physiopathological conception.

The bile represents a continuous secretion of the
hepatic cell, little if any influenced by the taking
of food. But it is not discharged continuously
into the duodenum. During gastric digestion, the
amount of bile entering the duodenum is minimal ;
the amount begins to increase rapidly, as soon as
protein cleavage products with acid chyme begin
to enter the duodenum from the pylorus, the height
being reached when intestinal digestion is at its
peak. This clearly shows the necessity of a mor-

6

LAPENTA: GALLBLADDER LESIONS.

[New York
Medical Journal.

phological and physiological mechanism to store the
bile during the time that its presence into the duo-
denum is not needed. Such an anatomicophysio-
logical mechanism is represented by the gallbladder
and the sphincter of Oddi, a neuromuscular mech-
anism, controlling the opening of the common duct
into the duodenum.

In 1887 Oddi undertook the study of the func-
tions of the gallbladder by performing cholecystec-
tomy in a large number of dogs. This operation
had already been performed by Zambeccari on the
advice of Galileo. Oddi's animals all survived the
operation, without exhibiting any untoward phe-
nomena. On killing some of these animals, long
after the operation, he found a dilatation of the
extrahepatic ducts, the common duct in some in-
stances being two to four times the original calibre.
Most characteristic was the dilatation of the cystic
duct stump, which uniformly assumed a gallbladder
shape, showing Nature's attempt to reestablish
integrity of the gallbladder sphincter mechanism.
These findings led Oddi to assume the presence
of this mechanism, which in later researches he was
able ta discover. This epoch making discovery was
made by Oddi (4) in 1887. This sphincter, com-
posed of fibres completely dififerent and independent
from those of the duodenal coat, is easily distin-
guishable even with the naked eye in the lower
animals ; it is not so easily distinguishable in man,
without adequate preparation, on account of the
thinness of the muscular coats of the duodenum,
although physiologically, in the human, it seems to
possess a more highly specialized function. Oddi
demonstrated that the sphincter can withstand a
pressure of fifty mm. of mercury or 675 mm. of
water. By a series of elaborate researches Oddi
(5) also demonstrated a special nerve mechanism
and demonstrated the special characteristics of the
ganglia supplying the sphincter and their inde-
pendence of the plexuses of Auerbach and Meisner.
He traced its reflex centre in the spinal segment
and succeeded in giving a complete explanation of
this special nerve mechanism. This extraordinary
great part of his research was later on confirmed
by the work of many eminent physiologists ; par-
ticularly prominent of which was the confirmation
of Oddi's researches by Doyon (6), who succeeded
not only in completely confirming Oddi's work but
also in establishing the special cytological charac-
teristics of the ganglia, controlling the innervation
of the sphincter. On the interrelated physiology
of the gallbladder and Oddi's organ, Bruno (7)
made in 1889 the most classical contribution. By
excising a circular piece of duodenum surrounding
the common duct sphincter, thereby preventing any
injury to its muscle fibres and innervation, and, by
stitching it to the abdominal wall, he was able to
observe the discharge of bile during fasting and
during feeding, and also the influence of the com-
position of foods on the secretion of bile.

A noteworthy, recent, confirmatory contribution
to the original work of Oddi has recently been made
by Mann (8). He has confirmed the finding of
the dilatation of the duct after cholecy.stectoniy, and
its absence, when the sphincter of Oddi is divide^
at the same time that cholecystectomy is performed.

He, too, has emphasized the interrelation of the
sphincter of Oddi and the gallbladder. Mann fur-
ther states that the gallbladder adds considerable
mucus to the bile, and that this mucus is absent
in bile coming from the hepatic duct.

PATHOGENESIS OF GALLBLADDER AND BILIARY
TRACT LESIONS.

There has been a recent attempt to divide these
lesions into certain clinical groups and to establish
certain etiological factors preponderatingly dom-
inant of each group. While this method has un-
doubtedly shed considerable light on the subject,
I fear that, after all, it will lead us back into the
old ontological nosographism and prevent us from
viewing pathogenesis from a physiopathological
viewpoint. It seems to me that it would materially
simplify our study if we should divide these lesions
into three general classes, namely:

1. A — Acute angiocholitis and cholecystitis, with and with-

out calculi.

B — Acute cholecystitis, with our without calculi.

2. A — Chronic angiocholitis and cholecystitis. '

B — Chronic cholecystitis, with or without calculi.

3. A — Cholelithiasis with chronic infection of the gall-

bladder.

B — Cholelithiasis, without demonstrable infection of
the gallbladder or bile.

The purpose of this physiopathological classifica-
tion is to emphasize in the mind of the clinician
the following points :

A. The existence of a diffuse, acute, infectious
process, involving the entire biliary tract. These
acute processes may or may not be associated with
stone. In most instances, the formation of calculi
takes place, when the process passes into the chronic
stage, following attenuation of infection. These
acute lesions are of course amenable to accurate
treatment, when the latter is well based on etiological
factors, which can usually be established.

B. The existence of primary gallbladder infec-
tions, both acute and chronic, without involvement
of the balance of the biliary tract.

C. The existence of both biliary tract and gall-
bladder lesions, in the primary acute form, due to
attenuated infection of hematogenous origin.

D. The existence of cholelithiasis in the gall-
bladder and dticts, without acute or chronic infec-
tion possibly due to a persistent hyperchbles-
terinemia.

Little if any importance is now attached to
the theory of ascending infection from the duo-
denum, since both from anatomical and physio-
logical reasons, this seems iinprobable. Of the
avenues of infection we must consider that of portal
origin, and that coming from systemic bacteremias
through the hepatic artery itself and directly to the
gallbladder through the cjj-stic artery. There does
not seem to be sufficient evidence to consider an
avenue of infection through the lymphatic circula-
tion, since the deflux of the lymph stream .seems
to be away from, rather than toward, these struc-
tures. Gilbert and Dominici (9) produced chole-
cystitis and angiocholitis experimentally, by sub-
cutaneous inoculation of attenuated typhoid cul-
tures, in rabbits, and colon bacilli in dogs. Any
lesion of the intestinal epithelium which can permit
the passage of bacteria into the portal radicles, must

January 1, 1921.]

LAPENTA: GALLBLADDER LESIONS.

7

necessarily be considered as potentially productive
of biliary tract infection ; and the infection of the
gallbladder can then take place through the infected
bile. In this instance, we must consider a primary
insult to the hepatic cell itself ; the gallbladder
mucosa and particularly the crypts of Luscka becom-
ing subsequently infected. The gallbladder can,
however, be directly infected by bacteria brought to
its structural elements by the cystic artery, from
any focal infection or bacteremia. Rosenow (10)
in my opinion has demonstrated this clearly and
irrefutably. He has further well illustrated the
tissue tropism of some of the bacteria concerned in
these infections. The hematogenous avenue of
infection is undoubtedly the most common one in
primary gallbladder lesions. In infections of the
bile capillaries it is indubitably the only one, since
it seems inconceivable to ascribe even one of these
cases to ascending infection.

PATHOGENESIS OF CHOLELITHIASIS.

The infectious origin of choleli'-hiasis was first
advanced in 1886 by Galippe (11). Naunyn (12)
later advanced this theory at the Medical Congress
at Weisbaden in 1891. Confirmation of this theory
was later brought by the researches of Welch (13),
Mignot (14), Cushing (15), and Gilbert and
Fournier (16). Somewhat startling was the state-
ment of Naunyn that cholesterin was not a specific
secretion from the liver, but that it was produced
from the bile by infection.

Much discussion is still raging between the
adherents of the infectious theory of gallstones and
the supporters of the chemical metabolic theory.
The partisans of the latter theory seek to explain
the formation of calculi on the basis of a hyper-
cholesterinemia. They completely reject the influ-
ence of infection in stone formation and insist that
an infectious process can cause gallstones only in
the presence of a high cholesterin content of bile.
Henes (17) asserts that many cases of cholelithiasis
show no demonstrable infection, and reports about
forty cases of cholelithiasis associated with a high
blood cholesterol content and free from any infec-
tious trace. The researches of Aoyama (18) are
in this respect highly suggestive. By subcutaneous
injection and by oral feeding of cholesterin and
some of its esters, he has succeeded in producing
gallstones or concretions similar to them in many
instances.

Cholesterin or cholesterol (Cj^H^gOH) is a com-
plex monatomic alcohol. It forms esters easily with
fatty acids. It is insoluble in water. It is present
in all animal tissues, especially in the central nerv-
ous system. In bile it is held in solution by the
bile acid salts and its soaps. The dry corpus cal-
losum contains as much as fourteen per cent., and
dried human liver, six to seven per cent. Most
gallstones contain as high as ninety-six per cent.
Its physiological role is as yet very mysterious. It
has been assumed that it acts as a protective agent
to the red cells, and has been used in the treatment
of pernicious anemia, with supposedly good results.
While a large number of cases of lithiasis are asso-
ciated with a high blood content of cholesterol, I
feel that it is impossible to establish the pathogenesis
of gallstones from this basis. The overwhelming

number of these cases is associated with demon-
strable infection. Careful study of stones in nearly
eighty-five per cent, of cases demonstrated a bac-
terial nucleus, with evidence of infection in the
gallbladder. That a high cholesterol content of the
bile is a factor cannot be denied, but it is at best
only a predisposing one and therefore of little etio-
logical value. It will be best for us to continue
to consider biliary concretions as monuments to
one time living bacteria.

THE GALLBLADDER AND BILIARY TRACT AS SOURCES
OF CHRONIC FOCAL INFECTIONS.

It is very easy in our consideration of the etio-
logical causes of gallbladder lesions to underestimate
the importance of chronic infectious processes in
these structures as focal infection factors, capable
of multivarious clinical manifestations. Thus we
have seen numerous cases of chronic pancreatitis
to be wholly dependent upon subinfection, main-
tained by disease of the gallbladder. Cures have
been systematically obtained in this case by chole-
cystectomy with common duct drainage. Of the
more distant efYects of chronic gallbladder infec-
tion, we wish to mention a type of severe secondary
anemia, associated with an increased fragility of
the red cells. These cases especially have been
encountered in association with common duct
stone, although we have had four cases that were
associated with chronic cholecystitis only. These
anemias which had resisted all dietetic and medicinal
treatment quickly yielded to cholecystectomy. I
cannot ascribe these results to anything but the
ablation of this active focus of infection, which
continuously added to the blood toxic products,
which acted hemolytically on the red cells. These
cases must not be confused with hemolytic icterus ;
they represent a type of secondary anemia due to
increased fragility of the erythrocytes, which is
encountered often in all chronic infections.

The primary object of this contribution is spe-
cifically restricted to the pathogenesis and physio-
pathology of these lesions. It is, however, neces-
sary to mention the occurrence of carcinoma of
the gallbladder, which often seems to be a terminal
event of chronic infection of the gallbladder, due
to the long continued irritation, from the presence
of stones. For obvious reasons it has been thought
best to refrain from treating of neoplasms of the
pancreas causing biliary obstruction.

Adhering to the limitations set to this contribu-
tion, no reference will be made to the clinical
manifestations as bearing on . their diagnosis and
treatment, with the exception of some brief mention
of our opinions in this regard. We hope to illus-
trate the lessons to be drawn from this contribution
in a future publication.

CONCLUSIONS.

1. Diseases of the gallbladder and biliary ducts
are principally produced through hematogenous in-
fections. Importance must be accorded in the his-
tory to the occurrence of typhoid, tonsillitis, and
other focal infections in the past history of the
patient. Previous disease of the vermiform appen-
dix must also be taken into account, as well as
concomitant incidence of chronic appendicitis.

8

KOUINDJY

MASSAGE IN SALIVARY FISTULA.

[New York
Medical Journal.

2. Oddi's researches show tliat the gall1)la(lder
is not a functionless organ, and that the addition of
nuicus in tlie I)ile by the gallbladder is of some
importance. In uncomplicated cases of cholelithi-
asis with the al)sence oi structural lesions of the
gallbladder, without active or ([uiescent infection,
cholecvstostomy is still sufficient.

3. Caution must, of course, be exercised to avoid
leaving in a diseased organ. On the slightest evi-
dence of chronic infection, cholecystectomy must
be performed.

4. The role of hypercholesterinemia in the eti-
ology of gallstones is regarded as a predisposing
factor. We feel that the chief pathogenic role is
to be ascribed to infection.

5. The role of gallbladder infections as chronic
foci, capable of setting up systemic metastatic lesions
elsewhere in the body, leads us to emphasize the
necessity of timely diagnosis and the importance of
cholecystectomy as a curative operation.

REFERENCES.

1. Reid, M. R, and Moxtgomerv, J. C. : .\cute Chole-
cystitis in Children as a Complication of Typhoid Fever.
Bulletin Johns Hopkins Hospital. 1920, xxxi, 7.

2. Hubbard, J. C, and Kimptox. A. R. : Gallstones. A
Statistical Study of Cases Occurring at Boston City Hos-
pital, Annals of Surgery, 61 :53S, 1915.

3. Jacobson, Coxrad : Gallbladder Disease, A Statistical
Study, Annals of Surgery, vol. i, September, 1920.

4. Oddi, R. : Di una specialc disposizione di sfintcre alio
sbocco del coledoco. Perugia, 1887, quoted by Luciani. L. :
Human Physiology, 2:214, 1913.

5. Oddi, R., and Rosciaxo, R. D. : Sulla existenza di spe-
ciale gangli nervosi in prossimita' delle sfintere del coledoco.
Monitore italiano di Zooloqia. Firenze, 1894, v, 216-219.

6. DovoN.: Archives de Phys. norm, et path., 1883,1884.

7. Brune: Arch, dcs Sciences biologiques de St. Peters-
burg, 1889.

8. Manx, F. C. : The Functions of the Gallbladder, An
Experimental Study, New Orleans Medical and Surgical
Journal, 1918, Ixxxi. 80-92.

9. Gilbert and Domixici : Angiocholite et cholecystite
typhiques experimentales, Coniptes rend Soc. de bid., 5-1033,
December 23, 18.

10. Rosexow, E. C. : Bacteriology of Cholecystitis and
Its Production by Injection of Streptococci, Journal .1. M.
A.. 63:1835, November 31, 1914. .\lso : The Etiology of
Cholecystitis and Gallstones and Their Production by In-
travenous Injection of Bacteria, Journal of Infectious Dis-
eases, 19:527, 1916.

11. Galippe, v.: Alode du formation du tartre et de
calcul salivaire, considerations sur la production des calculs
en general, presence des microbes on de leur germes dans
ces concretions, Jour, des Connaisanccs Med., 25 Mars.,
1886, Comp. rend. Soc. des biol., Series 8, 3:116, 1886.

12. Nauxvn, Bernard: Die Gallensteinkrankheiten,
Verhandl. d. Cong. f. inn. Med., 1891 ; Cf Nauxvx, Ber-
nard : A Treatise on Cholelithiasis, Xcn' Sxdenhani Soc,
158, 1896.

13. Welch, W. H. : .Additional Note Concerning the
Intravenous Innoculatton ot Bacillus Typhi Abdominalis,
Johns Hopkins Hospital Bulletin, 2:121, 1891.

14. Migxet (Quoted by Hartman, M. H.) : Patho-
genese de la lithiase, I'resse med., 3 (2 mars.), 1898. Also:
L'origine Microbiene des calculs biliaires. Arch. qen. de
W., 2:129, 1898.

15. Gushing, Harvey: Typhoidal Cholecystitis and
Cholelithiasis, Bulletin Johns Hopkins Hospital, 9, 91, 1898.

16. Gilbert and Fourniers : Lithiase biliaire experimen-
tale, Comptes rend Soc. de biol.. 936 (October 30), 1897.

17. Hexes, Edwin, Jr.: The Value of the Determina-
tion of the Cholesterin Content of the Blood in the Diag-
nosis of Cholelithiasis, Journal A. M. A., 63:146, July 11,
1914; Surgery, Gynecology, and Obstetrics, 23:91, 1916.

18. Aovama : Experimenteller Beitrag Zur Frage der
Cholelithiasis, Deutsch. Ztschr. f. Chir., 132:234, 1914.

Newton Claypool Building.

TREATMENT OF S.\LIVARY FISTULiE
BY MASSAGE AND HOT AIR.

By PlERRli KOUINDJY, M. D.,
Paris, France.

The utility of mas.sage in the treatment of wounds
and ulcers had been proved long before the war.
Some of my colleagues, Munter, Blach, Lanel, and
others, have published their observations on the
treatment by massage and hot air of varicose ulcers
and other forms of ulcers, which had resisted all
other therapeutic measures. In 1905 I reported a
case of an obstinate ulcer of the lower extremity
cured by massage. The ulcer was situated on the
anterointerior surface of the left leg. The patient
had syphilis. He had received internal medication
and external applications, with no result. Electro-
therapy, hydrotherapy, and hygienic measures had
no effect on the ulcer. ^Massage of the tissue sur-
rounding the periphery of the ulcer caused a healing
of the entire surface in six weeks by virtue of
increasing the resistance of the tissues.

Experience in the war showed that extensive
wounds with fistulje, or badly cicatrized, atonic
wounds or suppurating ones, finally cicatrized in a
definite fashion due to the massotherapeutic efforts
combined with hot air. My confrere and friend,
Dr. Cyriax, of London, has recently devised a
method of treating war wounds by massage. In a
communication published by his pupil, Dr. Louise
Bennet, one finds a record of suppurating wounds
cured by massage. In one case quoted, where the
patient had a large irregular wound of the left
thigh twelve cm. in diameter, and another small,
suppurating wound of the right thigh, with a tem-
perature of 37.9° C. in the morning and 39° C. in
the evening, digital massage and profound pressure
of the periphen,- with movements of both adjoining
articulations healed the wounds in a short time.

In my service at the Yal-de-Grace I found that
massotherapeutic maneuvres combined with hot air
gave excellent results in the treatment of vicious
cicatrices of the face in war injuries. The results
obtained by the use of these two physical agents,
as the case would indicate, were really remarkable,
even in cases of keloids which would become more
supple, less adherent, or even completely detached
in some cases. Frequently they would lose their
contractility ; the muscles and aponeurosis would
become detached. This wottld aid in reestablishing
facial symmetry in a greater or less degree. This
combination of massage and hot air in the treat-
ment of cicatrices of the face and cicatrices in
general prove that, due to the action upon the tis-
sues of the cicatrices and the adjacent tissue, they
produced a favorable modification in the circulation
and, as a result, in the nutrition of the tissues. I
then thought that this method, established by ex-
perience, would exert a favorable action upon the
lesions of the buccal mucosa in the case of wounds.
The following case will serve to illustrate this :

Last year our esteemed confrere, the well known
stomatologist. Dr. Roy, director of the dental school
of Paris, referred a young patient to me who was
suffering from lymphangitis of the right side of the
jaw, which followed the injection of a quantity of

January 1, 1921.]

KOUINDjy

MASSAGE IN SAIJVARV FISTULAS.

9

hydrogen peroxide into the subcutaneous tissue of
this region. The jaw was transformed into a liuge
tumor with an extensive lymphangitis. In the
centre of this inflammatory mass was a scaritied
area about tlie size of a ten cent piece ; in other
words, a generalized lymphangitis of the right side
of the jaw with considerable infiltration and a scar
forming in the centre. The patient was a girl of
eighteen. It was decided to use methodical mas-
sage and perhaps hot air in the treatment. Super-
ficial and deep rubbings were used as well as manual
concentric vibrations and digital centripetal pressure,
combined with a current of hot air, followed by
an internal application of hot air only. In order
to facilitate the resorption of the infiltration it was
decided to use the current of hot air by the buccal
route and directed on the internal surface of the
jaw. We used a simple paper tube to direct the
hot air current. In order to avoid any painful
sensations from the hot air the mouth was douched
with warm water from tinie to time between appli-
cations of the hot air. The lymphangitic pocket
diminished in size progressively, and at the end of
a dozen treatments the central area was no longer
visible, and at the end of fifteen treatments, to the
joy of the author of the unfortunate accident and
the patient, the symmetry of the patient's face was
restored.

This excellent result encouraged me to attempt
the method in the treatment of salivary fistulas
which were refractory to all nonsurgical treatment.
We soon had an opportunity to try the method
in a typical case of salivary fistula, and we present
the following case in which the patient. was cured
by the method of massage and hot air.

Case II. — Sergeant C, of 233d infantry, seen
August 29, 1918, in the fifth division of wounded
at the Val-de-Grace. There was some impotence
of the left shoulder caused by an atrophy of the
periarticular muscles of this articulation, and there
was a large cicatrix in the cervical region which
had been caused by the bursting of a shell. The
patient also presented a fracture of the mandible
badly consolidated, and a salivary fistula of the
left side of the jaw. The patient was injured
June 3, 1918. A curettage was done at the region
of the fracture of the inferior maxillary bone. This
procedure was not sufficient, however, as the wound
continued to suppurate. The surgeon then removed
a splinter of bone, but the wound continued to
suppurate. A month later the patient noticed that
saliva escaped through the opening at the base of
the wound, especially during mastication. From
time to time debris would escape through the open-
ing. When the patient entered the physiothera-
peutic service he held a compress in his hand as a
protection from the saliva which escaped from the
cicatrix. He had been receiving lavage of perman-
ganate of potash several times during the day, in-
jected into the external orifice of the fistula. The
nonconsolidated fracture presented a mobile frag-
ment surrounded by an inflammatory area especially
in the region of the fistula. There was also an
area of congestion of the cicatrix and an infiltration
of the jaw.

The general condition of the patient left much to

be desired. He was badly nourished, had difficulty
in masticating his food, and in addition there was
a constriction of the opening of the jaw, the si)ace
between the jaws being only eighteen millimetres.

I began to treat the fistula by massage, superficial
and deep rubbing, and centrij)etal vibrations from
the periphery to the centre, not touching the fistula.
At the same time the facial cicatrix was massaged
to make it more supple, less acDierent, and less con-
tracted. All of the massotherapeutic maneuvres
were executed first without hot air, later by a cur-
rent of hot air over the entire cutaneous surface of
the jaw and the fistula itself. Finally the current
of hot air was turned upon the buccal surface
through the opening of the mouth in such a way
as to bring it in contact with the internal border
of the fistula. As the application of hot air occa-
sioned an increase in the amount of heat aj^plied and
there was danger of causing a burn, or at least a
very painful sensation, it was necessary to interrupt
the application frequently and regularly every two
or three seconds. The treatments were terminated
by regular movements of the mouth.

The treatment began on August 20, 1918, and
soon gave encouraging results. On September 26,
1918, an examination revealed the facial cicatrix
more supple and less adherent, and the edema of
the jaw had diminished perceptibly. The fistula
had decreased in size but the saliva still escaped,
especially at the time of mastication. The patient
was able to eat more easily and masticate better, and
he could open his mouth a few extra millimetres.
On October 19, 1918, the fistula was closed, no more
liquid escaped, mastication was better, the mouth
could be opened wider, and the patient was better
able to eat. The facial cicatrix was more supple,
but still somewhat fibrous. The infiltration of the
jaw had disappeared. On December 17, 1918, the
fistula was completely obliterated, the infiltration of
the jaw definitely gone, the tissues of the cicatrix
had a normal appearance, the opening of the mouth
was about normal, thirty-three mm., and he masti-
cated his food as though there was no fracture of
the inferior maxillary bone. In any case the patient
looked very well. Other treatment he had received
enabled him to move his shoulder joint and bring
his arms to the same level. A simple suture brought
the two borders of the fistula together and removed
all traces.

How can we explain the action of massage
and hot air upon salivary fistulie ? Workers
who apply hot air therapeutically state that it
causes a hyperemia, which they also call an active
hyperemia. This hyperemia causes a local change
which may be compared to a caustic action. The
hot air produces in addition an analgesic action
upon the tissues and a progressive drying of the
secretions. This last ef¥ect can be compared to a
resection of the auriculotemporal nerve. As in this
resection, the hot air causes a decrease in the salivary
secretion with a resorption of the exudate of the
infiltrated regions. During massage the action
is mechanical and reflex. The mechanical action
exerts a favorable action upon the circulation and
the reflex action upon the terminal nerves, and an
increase in the nutrition of the tissues. The result

10

Sin-MAA': GASTRIC ULCER AND CANCER.

[New York
Medical Journal.

of the aclioii of the phyNical agents utiHzed, hot air
and massage, is an improvement in the arterial,
venous, and lyniphatic circulation. This gives iis
a clue to the progressive elimination of the morbid
elements of the wounds and of the salivary fistulae.

Therefore, we are of the opinion that before
deciding upon surgical intervention in the treatment
of salivary fistulae it is essential that we first attempt
a physiotherapeutic treatment, composed of appro-
priate massotherapeutic maneuvres, as, for example,
superficial and deep rubbings, light pressure, digital
vibrations, and a current of hot air applied by way
of the mouth to the two surfaces of the jaw, first
the cutaneous surface, later the mucous surface.
It is necessary to combine the two physical agents
so that the hyperemic action of the one is comple-
mented immediately by the mechanical action of the
other • so that tlie vital activities of the patient's
tissues are stimulated and the cicatrization of the
fistula is completed.

32 RUE d' Liege.

GASTRIC ULCER AND CANCER.*

A Case Report of Each.
By John W. Shuman, M.D., F.A.C.P.,

Sioux City, la.,

Visiting Physician, St. Vincent Hospital.

The diagnosis of stomach lesions is greatly aided
by X ray visualization. The two cases reported
below illustrate the diagnostic value of radiology
and the shadows show clearly the pathology present.

Fig. 1. — (Case I.) Arrow points to deformity on lesser curvature,
midway between cardiac and pyloric ends of stomach. Position,
prone. Time, two and one half hours after meal was ingested.

•Presented at the Twenty-fifth annual meeting of the Sioux Val-
ley Medical Association, held at Sioux Falls, South Dakota. June
23 and 24, 1920.

Fig. 2. — (Case I.) Arrow points to the defurmity which is still
present at four and one half hours.

Both patients were operated upon and the surgical
pathological findings confirmed the clinical diag-
nosis in each instance. The first case was diagnosed
clinically as a penetrating ulcer on the lesser curva-
ture, midway between the cardiac and pyloric ends
of the stomach. The second case was diagnosed as
malignant neoplasm involving the pyloric end of
the stomach and causing pyloric obstruction.

PENETRATING ULCER ON THE LESSER CURVATURE,
MIDWAY BETWEEN THE CARDIAC AND
PYLORIC ENDS OF THE STOMACH.

Case I. — Mr. P. H., aged seventy, was referred
by Dr. W. G. Rowley, of Sioux City, on September
27, 1919.' He complained of a burning sensation
in the stomach, and gave the history of having had
a stomach ulcer diagnosed and cured six years ago
by medical treatment. The highly suggestive symp-
toms of ulcer, i. e., hunger pain, food ease, and
hypersecretion, were present. Radiograms of the
stomach containing the barium and buttermilk meal
at two and a half and four and a half hours in
the prone position, showed a constant deformity on
the lesser curvature (Fig. 1), which was interpreted
as a penetrating ulcer. At eighteen and a half
hours the head of the meal was inidway through the
transver.se colon and a "fleck" (crater of the ulcer)
was easily observed in about the position where the
gastric deformity had been noticed the day previous.

The conclusion was drawn in this case that we
were dealing with a penetrating ulcer of the lesser
curvature of the stomach ; but malignancy had to
be considered on account of the age and appearance
(malnutrition) of the patient and the history of
chronicity. Celiotomy was advised and performed
on October 22nd, and a perforating ulcer, "dime

January 1, 1921.]

sHi■^rA^': gastric ulcer and cancer.

11

Fig. 3. — (Case I.) Arrows point to shadows which were inter-
preted as "barium flecks." Note that one is more distinct than the
others (ulcer crater filled with barium). Position prone. Time,
eighteen and one half hours.

size," found situated midway between cardiac and
pyloric ends of stomach, on the lesser curvature.
This ulcer was cauterized and excised and a pos-
terior gastrostomy performed. On January 15.
1920, Dr. Rowley reported that the man had gained

Fig. S. — (Case II.) Exposure made fifteen minutes after Fig. 4.

forty pounds in weight and was feeling "the l)est
in years."

MALIGNANT NEOPLASM INVOLVING THE PYLORIC
END OF THE STOMACH AND CAUSING
PYLORIC OBSTRUCTION.

Case II. — Mrs. M. E. G., aged seventy-two, was
referred by Dr. W. G. Rowley on November 10,

Fig. 4.— (Case II.) Time, immediate; prone position; arrows FiG. 6.— (Case II.) Exposure one hour after the taking of the

pointing to filling defect. barium meal shows the deformity copstant and delayed emptying.

12 KUSE: ACID

1919. She had lost thirty-fivc pounds in weight
during the past year, and could not retain food,
'["here was a freely movahle, smooth, well rounded
mass ahout the size of a small orange palpable in
the niidepigastrium. Radiograms made immedi-
ately, fifteen minutes, one hour, and eighteen liours

Fic. 7. — (Case II.) At eighteen hours; arrow points to small
portion of the barium meal stHl -remaining in the stomach. The
constant deformity and delayed emptying made for the diagnosis
of a gastric tumor.

after taking the barium and buttermilk meal,
showed a marked filling defect in the prepyloric
portion of the stomach (Fig. 2), which was reported
by the surgeon after the operation as a turkey egg
sized mass, of cauliflower appearance, found inside
the stomach, attached by a pedicle to the wall of
the stomach, on the lesser curvature about one
and a half inches from the pylorus. No perigastric
adhesions and no enlarged glands were found. The
neoplasm was removed and a gastroenterostomy
performed. This mass had evidently acted in a
ball valvelike manner to occlude the pylorus. The
patient died six days later. The pathological diag-
nosis of the tumor by Dr. Rowley was adeno-
carcinoma. X ray exposures and prints were made
by Maud H. Fair, x ray technician.

F"rANCES BuiLDINd.

Occupational Therapy for the Tuberculous. —

F. H. Hunt (Boston Medical and Surgical Journal,
Sepember 16, 1920) says that occupational thera-
py's chief aim is psychic and that, based upon its
l)sychic ef¥ect, it is a])plicable in all stages of tuber-
culosis, early and late, favorable and unfavorable,
each case presenting its own problem, and when
controlled exercise is added, physical upbuilding
with enhanced imniunitv results.

GASTRITIS. [New York

Medical Jouknai..

ACID GASTRITIS.
By Robert Hugh Rose, M. D.,

New York.
DEFINITION AND DESCRIPTION.

Acid gastritis is an inflammation of the stomach,
characterized by an increased secretion of hydro-
chloric acid and the presence of an abnormal amount
of mucus. Mild cases so much resemble simple
hyperchlorhydria that it is difficult to draw a sharp
line between these conditions. Severe cases so
much resemble ulcer that the differential diagnosis
is made with difficulty. This overlapping of symp-
tomatology is not strange because increased acidity
is present in all three and the symptoms are, to a
considerable extent, due to acidity. While, there-
fore, it is often largely a difference of degree which
exists between them, it is important to recognize
with which condition one is dealing, in order to
prescribe the proper treatment. In severe cases the
amount of mucus is so marked that considerable
attention must be directed to its removal.

ETIOLOGY.

Acid gastritis is due to the same causes as hyper-
chlorhydria. It is questionable whether the latter
disease can exist for many weeks without producing
some inflammation of the stomach and, therefore,
turning into acid gastritis. Since my article on
hyperchlorhydria (1) gives the causes in detail, I
will here mention them only briefly. Acid gastritis
is caused by seasonings, spices, acids, coffee, alcohol,
tobacco, irregular or rapid eating, overwork, worry,
violent emotions, and such surgical conditions as
chronic appendicitis, gallstones, and other similar
conditions. Infection of more or less severe grade
is, according to my opinion, secondary to these
causes. Germs from the nose and throat, as well as
those taken in the food, afe the source of infection.

PATHOLOGY.

The mucous membrane is congested and there is
])roliferation of secretory glands. When such in-
flammation is severe, connective tissue may, sooner
qr later, obliterate some of these glands until the
disease is transformed into gastritis with subacidity.

SYMPTOMS.

Appetite. — On account of the acidity, which pro-
duces better digestion and often increased motility,
the appetite is increased. It is well to bear this
point in mind, and, in cases where the appetite is
diminished, to look for some complication as
explaining the discrepancy. The complication may
be spasm of the pylorus (producing impaired gas-
tric motility), atonia gastrica, or a large quantity
of mucus.

Taste. — There may be a sour taste and this is
what should be found in uncomplicated cases.
Inflammation of the bile ducts and of the large and
small intestines account for the modification of this
symptom.

Heartburn. — A burning sensation in the esoph-
agus or stomach is nearly always present, either
regularly within one or two hours after meals, or
on occasions when foods which disagree are eaten.

Pain. — The pain which occurs with acid gastritis
varies from a slight to a severe one. It is some-

January 1, 1921.]

ROSE: ACID GASTRITIS.

13

times described as a burning i)ain because accom-
panied by heartburn. At times it is sharp enough
to assume a knifelike character. Owing to the
tendency for circular muscles at the pylorus and
cardia to go into spasmodic contractions, there may
be attacks of pain of a character comparable to
gallstone, kidney stone, or angina pectoris. Lesser
degrees of spasm of these muscles produce a sen-
sation of gnawing rather than actual pain. Spasm
in the upper esophagus causes a sensation of dis-
comfort which is variously described as a feeling
of suffocation, lump in the throat, or choking.

A'dusea. — It is natural for patients stififering from
this condition to complain of natisea. When spasm
of the pylorus causes the acid contents of the
stomach to be retained, it may produce nausea with
occasional vomiiling. In the more severe cases,
which are accompanied by a great deal of mucus,
vomiting at intervals is Nature's method of remov-
ing the mucus when it has accumulated. Thick,
tenacious mucus is more common with a siibacid
gastritis, but it is present in hyperacid gastritis
frequently enough to make vomiting of this char-
acter an important symptom. It must be remem-
bered that many of these cases are accompanied
by mucus in the esophagus, and its presence accounts
for some of the substernal discomfort in the itpper
part of the esophagus.

Examination. — Tenderness in the epigastric
region is more marked than it is in hyperchlor-
hydria, and it is present during the interval between
digestion as well as during the periods of digestion.

Test breakfast. — Examination of the gastric con-
tents after the usual test breakfast of bread and
water shows not only increased acidity but the
presence of muctis as well.

DIAGNOSIS.

There is no difficulty in making a diagnosis of
acid gastritis from the examination of the stomach
contents. The length of time the disease has
existed as elicited in the history together with the
severity of the symptoms will indicate whether
hyperchlorhydria or acid gastritis is to be expected.
Mucus in the gastric contents establishes the pres-
ence of inflammation. The amotmt may not be
appreciated at first, because thick mucus does not
always come through the tube when the test meal
is expressed. It may require several washings of
the stomach to remove all the mucus present.

PROGNOSIS.

Although acid gastritis requires more vigorous
treatment than hyperchlorhydria, the ultimate prog-
nosis is not as bad as at first might be supposed.
The causes, being about the same, are as easily
removed. Mild cases respond to treatment almost
as quickly as hyperchlorhydria. The more severe
cases require great care and persistence in the use
of therapeutic measures.

TREATMENT.

Prophylaxis. — This is the same as in hyperchlor-
hydria.

Active treatment. — The diet is arranged in a
similar way to that for hyperchlorhydria. It is
necessary to avoid acids, not only vinegar and lemon
but all fruits which are in the least degree sour,

such as cranberries, goosei)erries, .sour grapes,
cherries, apples, oranges, grapefruit, or berries ;
pies or dishes of any kind which have a sour flavor.
Sour wines cannot be taken. Articles which are
oversweetened are also injurious. Mustard, jjcpper.
hot sauces, spices, and foods which are pungent,
stich as mint, cress, radishes, turnips, onions and
garlic are absolutely contraiiulicated. Excessive
amounts of coffee and strong cigars should bd
avoided. Meals should be simply pre])ared, avoid-
ing rich dishes and fried foods and using only
enough salt to counteract the flat taste. The dietary
may be chosen from the following articles :

F«/.y.— Butter, cream, olive oil, and crisp bacon.

Carbohydrates. — Small amount of sugar, toast,
whole wheat and graham bread, corn bread and
muffins (made with especial care so as to be light),
plain soda crackers, unsweetened whole wheat or
graham crackers, baked or well mashed potatoes,
baked sweet potatoes, cereals well cooked or dry
cereals heated, simply prepared tapioca, lettuce,
celery, romaine, spinach, string beans, lima beans,
tender peas, butter beets.

Proteins. — Roast beef or lamb, broiled steak,
.broiled lamb or mutton chops, tender veal, fresh
fish, chicken, and turkey. Milk, cream cheese,
American, brie, camembert, cheddar, Swiss, Mc-
Claren's yellow and unsnappy cheese. Eggs either
poached, coddled, scrambled, soft boiled, or boiled
for thirty minutes. No pepper, mint sauce, hot
seasoning, onion, garlic, and only a moderate amount
of salt shottld be used in the preparation of the
proteins.

Drinks. — In addition to milk, which is generally
well taken, a moderate amount of weak tea, cocoa
(not too sweet), plain water or alkaline waters
are harmless. In severe cases a diet as for mild
ulcer is necessary.

Drugs. — By the use of a sufficient quantity of
alkalies the excessive acidity may at once be neutral-
ized and many of the symptoms, such as sour taste,
heartburn, pain and headache, cjuickly relieved, and
the gastric mucous membrane at the same time
soothed and its inflammation lessened. For this
ptirpose equal parts of calcined magnesia and
sodium bicarbonate may be given in doses of a
quarter to a half teaspoon a half hour to an hour
after meals, and repeated if necessary two hotirs
later — making in all six times a day. If this dose
proves too laxative, a mixture of equal parts of
bismuth and soda may be substituted in like amount
for each alternate dose of the magnesia and soda.
If more laxative is required the amount of the first
prescription may be increased, or if the acidity is
not very high, powdered rhubarb may be included
with a little oil of peppermint to improve the taste.

Mucus. — The- presence of muctis is a factor in
this inflammatory process which requires especial
attention both because it must be eliminated in the
ctire of the inflammatory process and because it is
responsible for much of the discomfort which these
patients" suffer. Twenty minims of sodium glycero-
phosphate to the teaspoon of water when adminis-
tered in a glass of hot water a half hour to an hour
before meals dissolves the mucus and washes the
stomach. This is an effective measure in that it

14

I.ni'V: GASTROENTEROLOGY AND THE MOUTH.

[New York
Medical Journal.

cleanses the stomach three times daily. In cases
accompanied by hotli a large amount of mucus and
(il)stinatc consti])ation a substitution of Carlsbad,
l^l)soni or Rochclle salts in hot water for the
glycerophosphate before breakfast works admirably.

Lavage. — Washing the stomach first with soda
and then with a weak solution of silver nitrate if it
can be done from three to seven times a week, at a
time when the stomach is empty, is more effectual
than the glycerophosphate treatment, and the
advantage of the use of silver nitrate in this way
may be seen in the much more rapid improvement
which takes place when it is employed. The stomach
is sensitive to silver nitrate and it must be used in
a weak solution at the beginning with a gradual
increase in strength, never enough to cause the
patient pronounced discomfort. A solution of one
to twenty thousand is strong enough for the first
lavage. This may be gradually increased, but it is
seldom necessary to go above one to eight thousand,
though some patients who have been accustomed to
very highly seasoned foods may stand one to two
thousand without discomfort. If it is difficult to
use lavage and the silver nitrate is strongly indi-
cated, one eighth to one quarter grain may be
taken in a glass of water half an hour before each
meal, but it should not be continued for more than
three or four weeks.

REFERENCES.

1. Rose, Robert Hugh: Hyperchlorhydria, New York
Medical Journal, April 10, 1920.

40 E.AST Forty-first Street.

THE MOUTH FROM A GASTROENTERO-
LOGICAL VIEWPOINT.

By Louis Henry Levy, M. S., M. D.,
New Haven, Conn.

The gastroenterologist is frequently consulted for
some mouth condition or mouth symptom and as a
result many unusual things are encountered. The
mouth is of interest to the gastroenterologist from
three points of view. Affections of the n;outh may
produce lesions in the stomach, intestines or even of
the appendix. Changes in the stomach and intes-
tines may manifest themselves by symptoms in the
mouth. Again abnormal conditions within the
mouth may produce other abnormal conditions of
the mouth. Ordinarily these latter conditions are
within the province of that highly specialized divi-
sion of gastroenterology — stomatology — but since
this specialty has not as yet been sufficiently devel-
oped it still falls to the gastroenterologist to
diagnose and treat mouth lesions with symptoms
referable to the mouth.

Conditions arising from within the oral cavity
are etiological factors in the production of lesions
in other parts of the gastrointestinal tract. The
relationship between apical abscesses, pyorrhoea
alveolaris and tonsillar infections in the production
of some cases of ulcer of the stomach and some
forms of appendicitis has been well demonstrated
by Rosenow who several years ago proved that the
same organisms removed at operation from excised

appendices or in the craters of ulcers were present
about the various structures in the mouth.

Herschcll and Abrahams in their excellent book
(1) state that it is probably no exaggeration to
assert that the commonest factor which determines
whether a given case of atonic constipation will pass
into the stage in which it is complicated by colitis
is the condition of the mouth. Quite apart from
the efticienc)' of the teeth as a masticating machine,
the presence of centres of pus infection from which
millions of virulent organisms are swallowed with
each mouthful of food must be a constant menace
to the integrity of the function of the gastrointes-
tinal tract.

Colyer (2) states that the food imperfectly masti-
cated and incorporated with infected saliva sooner
or later starts a catarrhal inflammation. Septic
gastritis may result. The septic material from the
stomach will find its way into the bowel and pro-
duce either constipation or diarrhea, and in some
cases mucous colitis. The acidity of the stomach is
not an absolute antiseptic to the organisms swallowed
and some of the cases of phlegmonous gastritis
occasionally reported are examples of bacteria
attacking the gastric mucosa in the presence of a
normal gastric acidity. The acid may to some extent
inhibit but not necessarily destroy bacteria. Chronic
gastritis in many cases is undoubtedly due to the
constant irritating action of bacteria swallowed in
the saliva and with the food. The source of the
bacteria is the teeth. Such a condition may persist
for years, often resulting in ulcer and only disap-
pearing with proper treatment of the teeth. Two
cases from my records will illustrate this.

Case I. — Miss R. F., aged twenty-eight, stenog-
rapher, with gastric symptoms of eleven years'
duration. The symptoms consisted of sour taste,
bad breath, occasional nausea, epigastric distress
after meals, lack of appetite, costiveness and nerv-
ousness. She had been operated upon twelve years
previously and the appendix removed. The symp-
toms at that time were similar to those of which
she now complained, operation having failed to
relieve them. Examination showed an undernour-
ished young woman with marked epigastric tender-
ness and with tenderness along the ascending colon.
She had very marked pyorrhoea alveolaris, pus being
readily expressed in goodly amounts from the gum
margins. Treatment with proper diet and medication
resulted in slight amelioration of the symptoms. She
had been advised to consult a dentist, which she at
first failed to do. This was insisted upon and with
careful prophylaxis of the teeth and gums and with
the extraction of some teeth her symptoms disap-
peared. She has had no recurrence of symptoms
in a year and even her weight has increased, from
ninety-eight to 113 pounds.

Case II. — Mrs. R. K., forty-five years of age,
houseworker, complained of epigastric distress and
pain for six years. The pain had recently become
almost constant and was aggravated by eating sweet
foods. The pain had occurred at night. There was
considerable belching, but no sour taste ; no nausea
or vomiting. The bowels were costive. She had
had an appendectomy and ovariectomy eighteen
years before. Examination showed a faint systolic

January 1, 1921.]

LEW: GASTROENTEROLOGY AND THE MOUTH.

15

murmur at the aorta. There was severe tenderness
in the epigastric region near the ensiform. The
tenderness extended for a sHght distance to the
right. Fluoroscopic examination showed dilatation
of the left auricle.

Treatment, consisting of regulated diet and medi-
cation, ofifered some relief, but not marked. Fur-
ther questioning elicited the information that she
had had occasional trouble with her teeth. They
appeared to be in good condition, and an x ray was
advised. A large apical abscess was found, the
afifected tooth extracted, and the diet and medication
continued. The symptoms gradually disappeared
and have not recurred in a year.

As Rosenow has pointed out, ulcer of the
stomach may also be caused in some cases by bacteria
from infections about the teeth. These ulcer cases
are the direct sequence of chronic gastritis, which
has resulted from foci in the mouth. I have in mind
one such case that I saw. A woman aged thirty-
eight with typical ulcer symptoms of fifteen years'
standing and especially severe epigastric pain
after eating, consulted me about her condition.
Medication and diet only gave occasional relief.
Although her teeth were flawless a concurrent attack
of neuritis of the arm aroused suspicion of the
possibility of an apical abscess. The x ray revealed
the presence of five apical abscesses. These were
treated and not only did the neuritis disappear but
the symptoms of gastric distress also.

Aside from the countless cases of acute and
chronic gastritis resulting from rapid or incomplete
chewing or chewing with poor teeth, there is a
group who might be properly classified as gum
chewers. These chew with the bare toothless gums
or with one plate and one toothless gum. Those
with the one plate I have found to be women whose
only reason for using the one plate, which was
an upper plate, was for cosmetic reasons. It
prevented the appearance of sunken in jaws. These
patients had even more difficulty in chewing than
did those who used the toothless edges of both
maxillae. The improper mastication, especially of
the coarser or more fibrous foods and incomplete
dextrinization of carbohydrates by means of the
saliva, tend to force food into the stomach in a
condition which does not allow the gastric juice to
act properly. The result is delay in gastric diges-
tion, overactivity of the gastric glands, hypermotility
and delay in the emptying of the stoniach contents.
Here are present all the factors for the production
of an inflamed mucosa. The condition being uncor-
rected, there follows in due course ulceration and
even later carcinoma.

Two patients of mine, both women, one sixty-six
years old and the other fifty-eight, had for years
been chewing with upper plates and toothless lower
jaws. For years their symptoms were suggestive
of a disordered gastric condition. The cause of
their gastric condition was apparent and they were
advised to have lower plates made, which they did.
With better mastication of their food and correction
in diet for the gastric condition they were soon in a
better state than they had been for years.

With the other class of gum chewers — those
without any teeth — who have for years been chew-

ing with their naked gums, I have record of a
woman of sixty-eight years of age who for twenty
years had been having gastric symptoms. There is
another case of a man of fifty-five years of age who
for four years had been having attacks of symptoms
pointing to gallbladder disease. Another patient
whose attacks of epigastric pain were excruciating
had an area of severe tenderness and resistance in
the epigastrium that covered a space of about two
inches. An x ray series showed a chronic pyloric
ulcer with some obstruction. His condition was a
surgical one, but he refused operation. He said
that he would never put store teeth in his mouth.
After three years, although he is seventy-one years
old, he still suffers from his severe pains and the
only relief obtainable is through morphine.

Case HI. — Still another case was that of a man
aged eighty years with a gastric history indefinite
for about six years but more definite for the six
months before I saw him. He had been gum
chewing for over ten years. His history and a hard
mass to the right of the epigastrium was suggestive
of carcinoma and this diagnosis was verified by the
X ray. He died before any surgical relief could be
attempted.

Symptoms within the mouth suggestive of or
pointing to conditions in other parts of the gastro-
intestinal tract are well known. We have come to
associate the bad, foyl taste and furred tongue with
a diminished gastric acidity or with constipation.
We know also that the sour taste and the burning
in the mouth when it does occur is a manifestation
of the hyperacid stomach. Cannon (3) states that
during sleep there is a regurgitation of gastric con-
tents into the esophagus and often into the mouth
in small quantities. As a result with the hypoacid
stomach there is the furred, thick tongue and with
the hyperacid stomach the clean, red and moist
tongue. I have seen patients who have told me that
they were awakened during the night or aroused in
the morning by a rush of very sour fluid from the
stomach into the mouth. One patient, a woman
aged thirty-eight, complained that she was often
awakened during the early morning hours by a
sudden desire to vomit and she would eject as much
as a pint and a half of very acid fluid that would
not only burn her esophagus and mouth but would
make lier teeth feel puckery. Examination of the
fluid showed a free acid content of sixty-eight.

Another mouth symptom, one not generally
known and yet indicative of a gastric condition, is
salivation without local cause. This symptom is
sometimes present in carcinoma of the stomach.
The exact mechanism of the symptom is unknown.
In patients with a definite gastric history suggestive
of carcinoma this symptom is of the utmost impor-
tance in the diagnosis. I have a record of two cases,
one a man aged forty-eight with gastric symptoms
of only one month's duration. The salivation was
persistent. X ray plates and operation revealed an
inoperable carcinoma of the stomach. The other
patient was a man sixty-five years old and his also
was a history of short duration, not over two
months. X ray examination showed a pyloric
obstruction. He died after exhibiting all the symp'
toms of a malignant growth.

16

/,/:/'}'; GASTROENTEROLOGY AND THE MOUTH.

[New York
Medical Journal.

Tlie third group ot conditions are not as com-
monly seen by the gastroenterologist as are the
affections of other parts 6f the gastrointestinal
tract. The mouth is a common site for the dentist,
the laryngologist, often the dermatologist, often the
general practitioner and less often the gastroenter-
ologist. Frequently a patient with a mouth lesion
will travel from one to another of all of these
specialists. Some conditions of the oral cavity
stand out from the rest and it is these that concern
the gastroenterologist.

Perhaps one of the commonest mouth complaints
is the canker sore. These may be present on the
tongue, the sides of the mouth, the gmns, the floor
and the roof. Differentiation as to etiology is of
vast importance in the treatment. I have seen some
that were frank cases of Vincent's angina and the
- organism could be isolated from the sore. Perhaps
the most characteristic feature about these was the
odor and the tendency to spread. Another group
of cases were those with a herpes of the mouth.
These patients gave a history of nervousness, of
canker sores occurring at intervals for years and
of the intense pain of the sores which seeined to
defy treatment.

The commonest cases of canker sores are those
resulting from the action of ulcerated infected teeth
on the mucosa or from an acid condition of the
mouth which may be associated with a hyperacid
condition of the stomach. As a result of this acid
condition of the mouth, there is produced by the
action of bacteria on retained food particles between
the teeth and in cavities, products of decomposition
which are irritative. After the formation of the
sores, the acid of the mouth also irritates.

Salivation without any other symptom is an occa-
sional symptom and careful examination will reveal
the presence of either rough or jagged teeth situ-
ated in the vicinity of the openings in the mouth of
the ducts from the salivary glands. This condition
is readily corrected by the proper treatment of the
teeth. Occasionally the salivation will persist for
a time after the teeth have l)een treated. When
such is the case suitable doses of either belladonna
or atropine will check the salivation.

One case of salivation was of considerable inter-
est. The patient, a woman fifty-four years old,
had been suffering fyr one year from excessive
salivation following the eating of spicy or vinegary
foods. Alcoholic drinks would also excite the flow
of saliva. There was often mouthfuls of .saliva
excreted. Even the drinking of cider with a low
alcoholic content' would stimulate this excessive
flow. Any of these stimulating substances would
give her a sensation as if her neck and the floor of
her mouth were swollen. The glands here would
swell and remain swollen for as long as twelve
hours. There would also at the same time be a
swelling of the parotid glands and her cheeks would
feel full and her face puffed. The condition was
undoubtedly one of a vasomotor disturbance in a
patient of a neurotic type.

Disordered tastes in the mouth are also frequently
complained of. A commonly encountered patient is
the one with the bad taste. Here, too, a knowledge
of the exact cause is of considerable aid in the

treatment. Aside from the mouth breather with
the perpetual bad taste in the morning, there must
be considered the hypoacid stomach with the furred
tongue. Bad teeth and pyorrhea must be looked
into and also a less common cause, submucous
abscesses with a starting point under some cap.
There must also be thought of the collection of food
debris in the large crypts of some tonsils. These
are present in small balllike masses and when they
are expressed from the crypts the bad taste disap-
pears.

Another frequent complaint is the brassy taste.
Examination of the mouth in these cases will reveal
the presence in or on the teeth of two different
metals. They may be a gold cap and a silver,
copper or zinc filling. When two different metals
are present in the mouth and there is an acid con-
dition of the saliva, there is formed spontaneously
a minute electric cell. An electric current is set up.
Electrolytic action on the metals occurs with the
solution of enough of one of the metals to give the
brassy taste. Neutralization of the acid in the mouth
usually causes a disappearance of the brassy taste.

Two cases that were baffling not only to me but
to others and the diagno.ses of which were only
made in one case three months prior to death and
in the other one month prior to death were in the
fir.st case pemphigus and in the second case perni-
cious anemia. In the case of pemphigus, the first
lesions were in the roof of the mouth under an old
plate and were attributed to irritation from the
plate. The sores resisted all treatment and gradu-
ally spread until the lips became involved and later
the face. When the face was attacked the nature
of the condition was quite clear.

In the second case there was a history of a
burning sensation of the tongue and gums at inter-
vals for over a year. The attacks usually lasted
two weeks. The first time I saw the patient he
had, besides the symptoms first mentioned, burning
in the epigastrium. There was marked congestion
of the tongue and lips. Three months after this
when I saw him again, he complained of a sore in
his mouth that persisted for a month. On another
visit three months after the last visit, there were
other sores in the mouth, and he also complained
of heartburn and diarrhea. Shortly after this the
sores began to increase rapidly and there was severe
pain on swallowing due to other sores on the walls
of the pharynx. His condition became poorly and
in the course of examination a blood count was
made and the hemoglobin determined. The result
showed the presence of pernicious anemia. The
patient died shortly afterwards.

There are many other conditions of the mouth of
interest to the gastroenterologist. No attempt has
been made to touch on the luetic, the tuberculous
or the carcinomatous lesions. The purpose of this
paper has been simply to tell of some of the inter-
esting conditions centering about the mouth which
are frequently encountered by a gastroenterologist.

REFERENCES.

1. Herscheli. and Abrah.^ms: Mucous Colitis.

2. Colyer : Dental Disease in Relation to General Medi-
cine.

3. Cannon: The Mechanical Factors of Digestion.

1172 Chapel Street.

January 1, 1921.]

B EH REND:

UPPER ABDOMINAL CONDITIONS.

1/

SOME UPPER ABDOMINAL TRUTHS AND
FALLACIES *

By Moses Behrexd, M. D.,
Philadelphia.

It was my good fortune to have been a general
practitioner lor fifteen years and during half of
this period to have been a socalled internist. Having
had the opportunity of performing operations in
my surgical cases it was often possible for me to
compare the results of medical and surgical treat-
ment. This preliminary training was undoubtedly
an important factor in aiding at the arrival of
conclusions in making diagnoses. It is not only
important in the preliminary understanding of the
case but also in postoperative complications, when
one's training in physical diagnosis assists in the
treatment of the case. The diagnostic ability of
the physician is in all probability taxed to a greater
degree in upper abdominal conditions than in those
below the umbilicus.

The main point at issue between the internist and
the surgeon is the curability of ulcers of the stom-
ach, as well as the advocacy of the cure of gall-
bladder conditions by a method to be discussed later
in detail. From my own early experience I can
truthfully say that I do not recall a single case in
which I was reasonably certain that a cure had been
effected. The internist cannot prove that he has
cured his patient, even if the radiologist reports the
ulcer to have healed. The symptoms ot indigestion
will still remain and it will be finally the surgeon's
duty to operate. While I would not oppose the
treatment of ulcers of the stomach or duodenum in
their inception, still I believe that in a symptomatic
condition lasting over a prolonged period of time
surgery is the proper course to pursue. That period
of time may vary, depending on the individual and
also upon the symptoms. Medical treatment with-
out relief should not be extended over a few weeks.
There must not be a time ^ limit, so to speak, for
those who have been chronic sufferers from indiges-
tion for many years. Here the internist does posi-
tive harm by attempting to cure a socalled healed
ulcer, perhaps a cancer in its early stages, or a
fulminating type of cancer in which the symptoms
reach their height in a few weeks. There is jiist
as much chance for an internist to cure a callous
ulcer as there is for an obstetrician to determine
the sex of the child in utcro. These ulcers usually
found in the stomach are dense and nonresistant.
They feel like a scirrhus of the breast. The ulcers
are often in a mass of adhesions and at times it
is impossible macroscopically to distinguish them
from carcinoma of the stomach. The tendency of
ulcers to undergo a malignant change is another
argument why these cases should have a timely
operation. This is a timeworn admonition, but
there are still many who disregard the warning and
continue to treat these cases until surgery can do
no good.

In duodenal ulcers there is not so great a ten-
dency to undergo cancerous degeneration, but the
danger of hemorrhage and perforation of this type

*Read before the Association of Ex-Resident and Resident Physi-
cians of the Mt. Sinai Hospital, November 3, 1920.

is great. \'ery few adhesions surround duodenal
ulcers, which accounts for the fact that when a
duodenal ulcer perforates there is a free flow of
intestinal contents into the abdominal cavity. The
gastric ulcer may also bleed and perforate. In
these there may be a perforation without much
leakage on account of a barrier of adhesions being
thrown quickly around the opening, preventing
serious contamination of the abdominal cavity. The
readiness of gastric and duodenal ulcers to bleed
and perforate should put these cases in the surgical
class without subjecting them to prolonged medical
treatment.

Speaking of hemorrhage recalls the history of a
boy, about sixteen 3-ears of age, who was admitted
to the hospital, suffering from hematemesis. On
account of a previous history of hemorrhage we
considered it advisable to operate on him. Prepara-
tions were accordingly made for the following day,
but during the night a concealed hemorrhage de-
veloped and he died before morning.

What, then, is the proportion of cases which the
surgeon cures, compared with those cured by the
internist ? Medical cures are few, while the sur-
geon who is able to excise these ulcers, preferably
by means of the cautery, has a large percentage of
cures. There is no question that excision of the
ulcer bearing area and a properly placed gastro-
enterostomy give the best results. A gastroenter-
ostomy is not essential in every case. It depends
upon the situation of the ulcer and the judgment
©f the operator as to whether the incision has en-
croached too far on the lumen of the stomach.
There is no question that the patient is cured of
an ulcer that has been excised, but this does not
prevent a recurrence of ulcers. These may be at
a different site in the stomach or at the gastro-
jejunal opening. A recurrence at the latter posi-
tion is due to the same process that caused the
original duodenal ulcer and not to the use of non-
absorbable suture material. This technical ques-
tion, however, need not be discussed fully here.
Suffice it to say that in all the gastroenterostomies
which I have performed or reopened, the non-
absorbable suture was not the cause of marginal
ulcers.

The fact that patients return to the internist after '
operation does not mean that the particular opera-
tion has failed. Contributing factors are indiscre-
tion in diet, improper postoperative treatment, and
inability or refusal of the patient to put himself
in the hands of the internist so that his future
course may be guided by him for at least a year.
This probably is the most important part in the
final cure of ulcer patients following operation.

The recent work of Lyon on the biliary secretions
may be important from a diagnostic viewpoint, but
it has led to numerous fallacies. It is a diagnostic
aid determining solely by the character and appear-
ance of the bile which portion of the biliary tract
is diseased. This is done by means of a duodenal
tube. I have tried the test in cases of chronic
jaundice, but did not meet with any success. The
reason was evident at the operation, when the fol-
lowing diseased conditions were found: In one case
there was a stricture of the right and left hepatic

18

BHHREXD: UPPER ABDOMINAL COXDITIOXS.

[New York
Medical Journal.

ducts; in another, there was a new growth in the
head of the pancreas ; in a third, there was a stone
tightly impacted in the papilla of Vater, and so on.
It is apparent, therefore, that even from the view-
point of diagnosis the test is not necessary, but it
does complete the study of these cases.

In regard to chronic jaundice it is unfortunate
that many physicians consider that the longer the
jaundice exists the less danger will there be of
hemorrhage following operation. The trouble in
the past has been that the waiting period before
operation has been extended entirely too long. It is
difficult to give any hard and fast rules to follow,
but I believe two to four weeks' observation and
study are sufficient. The urgency of the symptoms,
such as the presence of Charcot's fever, intense
itching, and other constitutional symptoms, ought
to make some impression on the internist. The
danger in waiting is due to the degeneration of the
organs, the heart especially, the liver itself, the
spleen, and the sympathetic system. Prolonged
complete obstruction will have the same effect on
the liver as a stone will have on the kidney, namely,
the liver will practically cease to functionate. It
has been my experience that if, upon opening the
common duct, watery bile exudes, a guarded prog-
nosis must be given. The following case will l)e of
interest :

C.^SE I. — A woman, aged sixty-two, with a history
of a cholecystectomy having been performed a few
years ago. A second operation was performed by
me two and a half years ago for chronic pancreatitis.
At that time her common duct was drained with
a T tube for eight months. The patient remained
well following the last operation until two weeks
ago, when she became intensely jaundiced, followed
by chills, fever, and sweat. To guard against any
possibility of bleeding we gave the woman a vene-
clysis of two per cent, calcium lactate solution tho
day before operation and immediately following-
operation. There seemed to be a greater tendency
of the blood to coagulate following this treatment.
It must be borne in mind, however, that all measures
used to prevent hemorrhage in these cases may be
fruitless. The head of the pancreas in this case was
of stony hardness, carcinoma being suspected. The
common duct was greatly dilated and resembled a
coil of intestine. It contained about four ounces of
bile. An anastomosis was made between the com-
mon duct and the stomach. The first twenty-four
hours the patient vomited large quantities of bile,
after which the vomiting ceased following gastric
lavages. On the second day her color had changed
from deep yellow to pale yellow. The patient made
a good recovery.

In contrast to this case let me cite the following,
which shows the inadvisability of waiting too long.

Case II. — A woman, about forty-five years of
age, was operated on for chronic jaundice, the dura-
tion of which was several months. Her myocar-
dium was already aflfccted and her kidneys were
not normal. In this case a .stone was found tightly
imbedded at the papilla of Vater, necessitating a
choledochoduodenotomy. The patient did well for
forty-eight hours, when the myocardium gave way
niul she succumbed to the deleterious effects of long

continued jaundice. There was no secondary hem-
orrhage in this case.

It would be a mistake, in a paper of this char-
acter, not to present for your consideration cases
in which it was difficult to make a diagnosis. A
case of great interest was that of a young man on
whom we had operated two years ago for acute
appendicitis. Four days before admission he com-
plained of upper abdominal pain coming on sud-
denly. Examination revealed a rigid abdomen, the
patient's expression was anxious, but a rather odd
feature was that vomiting was not an important
symptom. A diagnosis of ruptured duodenal or
gastric ulcer was made. At operation there was
found comparatively little of the contents of the
duodenum in the peritoneal cavity. The perforated
ulcer was excised with the cautery. A gastroenter-
ostomy which had been our custom in the past was
not made. The abdomen was washed with quarts
of salt solution. This patient made a good recovery.

The brother of a Philadelphia physician was
taken suddenly ill about 7 a. m. He imme-
diately went to his office, where on examination
was found a universally rigid abdomen. He
had vomited and felt nauseated. His skin was
cold, his face pale, and he seemed to be in a .state
of shock. There was a previous history of indiges-
tion. I confirmed all the subjective and objective
symptoms and made a diagnosis of a ruptured gas-
tric or duodenal ulcer. At operation no perfora-
tion was found, but instead a subacute appendicitis.

A woman about forty-five had been under the
care of a competent general practitioner for some
time, who had observed her in several attacks which
he thought was appendicitis. The pain was always
in the right iliac fossa until the last attack, when the
pain occurred higher up and also radiated to the
left side of the abdomen. The physician then be-
came suspicious of gallstones, which diagnosis was
confirmed with the coexistence of chronic appendi-
citis. At operation the pathology was found as
diagnosed, but in addition an abscess of the pan-
creas was revealed. This was opened and drained.
The pain on the left side can be accounted for by
the abscess of the pancreas.

In conclusion, it must be evident to you all that
the closest cooperation must exist between the in-
ternist and the surgeon. While the internist should
treat gastric and duodenal ulcers in their inception,
considerable harm has been done by the watchful
waiting poHcy. It is impossible to cure the hard,
callous ulcer without operation. The internist can-
not prove he has cured his ulcer patient, while a
thorough operation will. After operation, patients
nust be impressed concerning the necessity of plac-
i;ig themselves in the hands of a co npt'ent phv-
sician for at least a year. It is a fallacy that the
longer jaundice is present the less likelihood will
there be of a secondary hemorrhage following
operation.

The sooner operation is performed in ca.ses of
chronic jaundice, the better will be the prognosis.
The metliod advocated by Lyon completes the study
of the case and assists in the diagnosis, but cannot
be considered useful as a curative measure.

1427 North Bro.\d Street.

January 1, 1921.]

SAPHIR: CAUSES OF PRURITUS ANI.

19

CRYPTITIS AXD 1 1 VPERTROPHIED
PAPILLA AS CAUSES OF
PRURITUS ANI*
By J. F. Sapiiir, M. D.,
New York,

\'isiting Surgt'cm, Diseases of the Rectum ami Anus, People's Hos-
pital; Assistant Surtfein, Rec'al Department, Out Patient De-
partment, Gouvcrneur Hospital; Chief of Clinic, Rectal
Department, Stuyvesant Polyclinic, Etc.

At the junction of the lower portion of the rectum
with the anal canal is a distinct Hne of demarcation
known as the white hne of Hilton, also known as
tlie mucocutaneous junction. Here are situated the
anal papilla? and the crypts of Morgagni. These
papillae, from three to twelve in number, look like
small tits, or small saw toothlike triangular projec-
tions. Concealed behind these papillae are the
openings of the crypts of Morgagni, or anal pockets.
Some of these are merely slight depressions, and
others form distinct sinuses. This area, known as
the anorectal line, linea dentata, or the white line
of Hilton, is of especial interest because it is the
seat of inflammatory conditions which present symp-
toms out of all proportion to the lesion affecting
them.

Hypertrophied papillae and cryptitis are the most
frequently overlooked causes of pruritis ani. You
will often find patients who have undergone an
operation for hemorrhoids, which had been diag-
nosed as the cause of the pruritus, still suf¥ering
from itching as severe as before the operation.
These patients as a rule have been and still are
victims of cryptitis. On using a bent probe, the
inflamed crypts can be located running into and
underneath the puflfed up skin tags, and can be
located in the same manner as when searching for a
blind internal fistula.

Those patients who have had external and in-
ternal hemorrhoids removed at the same time, have
their crypts removed with the external hemorrhoids
and are cured of the pruritus. We take for granted
that the pruritus these patients have been suffering
from was due to no other cause than cryptitis, which
was masked by the fact that the patient was a
sufferer from internal and external hemorrhoids,
and the severe itching was attributed to them rather
than to the real cause.

These crypts act the same as blind internal fis-
tulae, and most of these fistulae have their original
focal points of infection in the crypts of Morgagni.
These crypts often get clogged up, and an inflam-
matory process follows, resulting in the formation
of an abscess, which gives the usual symptoms of
a perianal or a perirectal abscess, and these often
extend and produce large perianal, perirectal, or
ischiorectal abscesses. The crypts of Morgagni,
when inflamed or infected, cause a discharge of
various types of bacteria, depending upon the type
or types causing the infection, and the continued
irritation caused by the discharge produces first
itching or pruritus, then the condition becomes ag-
gravated by scratching. Patients suffering from
cryptitis will invariably complain of itching espe-
cially intense after defecation, due to the secretion
or discharge being expressed from the crypts by the

*Presented at a meeting of the Clinical Society of the Out Patient
Department, Gouverneur Hospital, November 4, 1920.

exjiulsion of the fecal mass and spread about the
. anus.

The hypertrophied papilhc arc the most frequent
cause for the socalled neuralgia of the rectum,
produced by the contraction of the sjjhincter muscle
upon the hypertrophied papillae, and the pressure
produced upon the nerve endings of the papillae
transfers and transmits the pain.

Frecjuently small masses of fcca! matter or
foreign bodies are arrested or become lodged in
these pockets and produce local and reflex irritation.
The crypts become clogged, and the decomi)osition
of the fecal matter or retained secretion causes irri-
tation, followed by inflammation called cryptitis,
which frequently goes on to pus formation! The
accumulated discharge overflows from the crypt,
causing moisture, irritation, excoriation, and itch-
ing of the anus.

Frequently patients complain of a prickling pain,
or of an uncomfortable feeling immediately after
stool. Others complained of this pain at no other
time than immediately after stool, probably caused
by some of the hypertrophied papillae being caught
in the grasp of the sphincter muscle, and the itching
produced by the expression of the discharge from
the crypts during defacation.

The hypertrophied papillae, when caught in the
grasp of the sphincter muscle, cause as severe pain
as that produced by anal fissure, which is caused
by hard stool getting caught in one of these
semilunar valves, and this is torn more and more
at each succeeding fecal movement, until a raw
ulcerated surface is produced, which is stopped only
at the mucocutaneous junction.

Inflammation of the papillae and hypertrophied
papillae are frequently associated with cryptitis, and
where a cryptitis exists the hypertrophied papillae
act as dams, preventing the discharge from the
crypts, and resulting in abscess formation. Treat-
ment consists in removing the papillae, when hyper-
trophied, under local anesthesia, and in opening and
cauterizing the crypts when inflamed or infected.
Inject a one fifth or one sixth per cent, solution
of quinine and urea hydrochloride into the base
of these hypertrophied papillae and snip the papillae
off as close to the base as possible. By everting
the anus, you may bring the papillae into view, or,
if necessary, use a fenestrated rectal speculum for
the purpose. It is never necessary to use a general
anesthetic. Bleeding is a negligible quantity, and
the after treatment consists of local applications of
silver nitrate, ten per cent., or ichthyol in glycerin,
ten per cent., or balsam of Peru every other day
until the parts are healed, usually two to four weeks.

For cryptitis inject the parts of area about the
crypt, including the hypertrophied papillae, and
excise the crypt and the papilla in a V shaped
incision, cauterize the base of the crypt with silver
nitrate, ten per cent., and treat as above. With a
bent probe one may locate the crypts, and frequently
topical applications of pure ichthyol by means of the
probe dipped into the ichthyol and passed to the
bottom of the crypt, may clear up an ulcerated and
inflamed crypt.

Case I. — H. S., fifty-six years old, referred to
me by Dr. A. J. Zobel, of San Francisco, gave a

20

s.ii'iiiK: Causes oi- rkChTrus axi.

I Xkvv Vok k
Medical Joursai..

history of constipation for the past fifteen years,
otherwise no trouble until six months ago, when he
noticed itching in and about the anus and a soreness
on the left cheek of the buttock near the anu>.
This itching would at times spread anteriorly to
the scrotum. He had received treatment at the

Fic. 1. — A, Houston's valves; R, longitudinal muscular coat; C,
rectal ampulla; D, columns of Morgagni; E, crypts of Morgagni;
F, external sphincter; G, Internal sphincter.

hands of a few physicians and by means of salves
and suppositories got ;?light temporary relief, but
the itching .still persisted and unconsciously he
scratched the parts, so much so tbat the parts grew
sore from the scratching, lixamination revealed
the parts reddened, skin cracked, moi.sture and red-
ness over the anus and anteriorly involving the
scrotum ; no protrusions, no induration except a
thickening of the skin, giving it a leathery feel ;
some scratch marks, and a puffiness of the skin
which ordinarily would be pronounced skin tags or
external hemorrhoids. On everting the anus, espe-
cially over the puffed up skin, and having the patient
strain down, I could notice small papillae behind
which were inflamed crypts. These became very
distinct and, on inserting a bent probe, the tip of
the probe could be felt moving with freedom under-
neath the skin on manipulation of the probe. This
actually can be considered a blind internal fistula.
Under local anesthesia of quinine and urea hydro-
chloride, one fourth per cent., I slit the tract open,
the same as I would in a blind internal fistula,
trimmed the edges to prevent interference with
proper drainage, cauterized the base with ten per
cent, silver nitrate, inserted a small drain ; the man
went about his business and called for his local
aftertreatment every other day for the first week.

and then once a week after that; and after twelve
treatments was cured. He is well today.

Case H. — C. J., forty-nine years old, referred
to me by Dr. J\I. I.ewson, clothing salesman by
occupation, felt well until eight months ago, when
he began to notice itching, especially severe at night ;
he also had itching during the day which was so
intense that it interfered with his business. In the
midst of a conversation with a customer, his hand
would automatically or reflexly go to his buttocks
or anus, which he was compelled to pat or touch
because he was ashamed to scratch, and, as he
described it, "the more you touch or pat the part,
the more it itches." He got so that he was ashamed
to wait on a customer. He received treatment at
the hands of a few physicians by means of salves
and suppositories, and was treated for eczema by
one or two doctors, but without relief. He had no
protrusions, had no swellmg or abscess at any time,
his bowels moved regularly, had never noticed any
blood or mucus with his stool, but he complained
very much of itching after a bowel movement;
the parts were ver}- wet, and the moisture from the
anus went down to the scrotum, causing also itch-
ing of the scrotum. His chief complaint was mois-
ture and itching, especially severe at night and
immediately after stool. Examination revealed a
condition almost the same as above, a cryptitis.

Under local anesthesia of quinine and urea hydro-
chloride, one fourth per cent., the crypts were slit
open, the edges trimmed to insure proper drain-
age, the base of the cry])ts cauterized with ten per
cent, silver nitrate, a small drain inserted, a gauze
dressing and a T binder applied, and the j^atient
went home to return every other day for treatment.
He obtained immediate relief from itching, and was
able to attend to business without the fear of the
necessity to .scratch preying upon his mind.

Case HI. — A. R., twenty-eight years old, opera-
tor, gave a history of having had protrusions and
much itching for the past two years ; went to a
doctor who treated him for piles with salves and
suppositories, without relief. He could not sleep
at night on account of the itching, and this itching
became more intense after inserting the supposi-
tories. Three months' ago he was operated upon
at the Post-Graduate Hospital, was in the hospital
for a week, but had had no relief from the itching ;
in fact, he asserted that the itching had become more
intense since the operation. He could not sleep
on accoimt of the itching, which awakened him three
or four times during the night. He had no blood
or pus, no pain or protrusions. He had occasionally
made the parts bleed from the vigorous scratching,
consciously or unconsciously. Examination re-
vealed very red, inflamed, and angry looking but-
tocks and anus, the redness and inflammation reach-
ing anteriorly to the scrotum and involving the
dorsum of the penis, and posteriorly over the skin,
reaching a line parallel with the tip of the coccyx.
The .skin was .scaly and thickened, covered with
scratch marks, .some puffiness of the skin about
the margin of the anus (skin tags), which, on being
everted, exposed to view a number of hypertrophied
papilla?, behind which were large openings of in-
flamed crypts, from which was noted a mucoid

January I, 1921.]

DRUECK: EXCISIOX Of CANCEROUS RECTUM.

21

secretion. A diagnosis of cryptitis was made, and
under local anesthesia, as described above, I slit open
four inflamed crypts, removed the hypertrophied
papillae, cauterized the bases of the crypts, applied
the gauze dressing and T binder, sent the patient
home, and for the first time in thirteen months
that patient slept through the night. He has been
relieved of itching and the inflamed condition of
the parts, and is attending to business.

Case IV. — S. R., fifty-seven years of age, manu-
facturer, referred to me by Dr. Arnold Sturnidorf,
gave a l\istory of having felt well until nine months
ago, when he noted itching of the anus. He sought
relief at the hands of a number of doctors, without
success. He was sent to a prominent skin specialist
who said he had eczema ; he was treated for that
condition but without relief. He still had the
severe itching, more severe during the day and
when walking, and recently this, itching had begun
to disturb his nights. He had also noted moisture
and wetness of the parts ; no blood, no pus, no pain,
nor mucus. Examination revealed four distinct
inflamed crypts, which I slit open under a general
anesthetic, kept him in the hospital three days, and
since then he has had no itching whatever.

It may be of interest to note that in all of these
cases I have been able to segregate successfully the
Streptococcus fsecalis, and have used the autogenous
vaccine without much success, although in about
thirty-six cases of pruritus ani, the autogenous vac-
cine of Streptococcus f scabs worked like a charm.
, In fact, in one case in particular, a doctor, of
Binghamton, N. Y., who had suffered from pru-
ritus ani for over fifteen years, and who had tried
almost everything that was invented either to relieve
or cure itching, got no relief whatever until I had
prepared for him a bottle of autogenous vaccine
of a culture of Streptococcus fascalis removed from
one of his inflamed crypts, and which he injected
himself. He obtained absolute relief from itching-
after the second injection, and when I last heard
from him he was entirely well.

However, I consider the removal of the cause as
the safest and most permanent form of treatment
to effect a cure. The Streptococcus faecalis, an
aerobic bacillus, is one of the most fre(|uent inhab-
itants of the crypts of Morgagni, and is the most
frequent offender in causing cryptitis and its result-
ing pruritus ani. The injection of an autogenous
vaccine (not a stock vaccine) has been successfully
used in making the Streptococcus faecalis inactive,
relieving the pruritus, and in healing the inflamed
crypt, but by slitting open the inflamed crypts and
obHterating the canal as you would in a blind
internal fistula, you entirely do away with any
desirable or ideal location for the growth of the
Streptococcus faecalis.

345 West Eighty-eighth Street.

A Contribution to the Histopathology and His-
togenesis of Syringomyelia. — G. B. Hassin
(Archives of Neurology and Psychiatry, February,
1920) concludes that in syringomyelia we possess
a number of specific pathological changes which
totally differ from those to be found in any other
spinal cord lesion — changes which stamp syringo-
myelia as a distinct anatomicopathological entity.

EXCISION OF CANCEROUS RECTUM
THROUGH VAGINAL SECTION.

By Charles J. Drueck, M. D.,
Chicago,

Professor of Rectal Diseases, Post-Graduate Medical School anil
Hospital, Rectal Surgeon to People's Hospital.

In women ])atients the perineal removal of can-
cer of the rectum may .sometimes be much facilitated
by section of the posterior vaginal wall and
perineum. The operation is practical only when
tumor is movable, and is situated in the lower half
of the rectum. If it is as high as the rectosigmoid
junction, then the combined abdominal and vaginal
operation should be employed. It is quickly per-
formed with less technical disadvantage because
ample working space is provided. There is less
traumatism and hemorrhage, and consequently les^<
shock. The technic can perhaps be best described
in the following case :

Case I. — Mrs. D., aged forty-eight years, had
borne eight children of whom six were living; the
other two died in childhood. Menstruation was
regular and normal up to eighteen months ago but
none since then. About one year ago there was a
])rotrusion at the anus about the size of a lima bean
(said to have been a hemorrhoid), which disap-
peared under treatment by her physician, and had
not reappeared. There was no protrusion at
present. For the past six months she had lost
blood from the anus. It came in gushes without
relation to her bowel movements and was some-
times so severe as to cause her to faint. Her former
weight was 200 pounds ; weight today 163 pounds.
She had had no formed bowel movements for the
past two months, and lately had had only liquid

Fig. 1. — A schematic illustration of the location of the cancer.

stools obtained by the use of Epsom salts. There was
a feeling of weight and a bruised or sore feeling in
the rectum, but no definite pain. She said she could
not have an evacuation without the use of
cathartics, which produced a temporary flushing
accompanied with much colic. She had abstained

22

DRUECK: EXCISION OF CANCEROUS RECTUM.

[New York
Medical Journal.

Fig. 2. — Vaginal wall incised
and the rectum exposed.

from eating rather than use the saHnes and had
subsisted on toast, soup and tea for the past month.
Inspection of the anus was negative; it was in its
proper location, not retracted and pr sented no
protrusion.

In a digital examination of the rectum '■•e finger

entered the rxtuu for
about an inch and a
half, when it came in
contact with an ede-
matous fold of mucous
membrane through
which there was a very
small passage. The in-
dex finger could not be
introduced and the re-
sistance was firm and
hard. At the first touch
the swollen mucous
membrane felt like an
intussusception, but the
deeper feel of the mass
behind was very dif-
ferent. The growth
appeared free from the sacrum but attached to the
uterus.

Vaginally, the tumor was easily defined, beginning
two inches from the vulva and extending up behind
the cervix. The vaginal mucous membrane was
free from the tumor, but the uterus was fixed.
Bimanually, an index finger in the rectum and a
hand above the pubes determined the mass almost
filling the pelvis. The x ray photo showed a large
mass filling the rectum, but no evidence of dis-
ease in the_ colon above. The patient was told
frankly that she had a cancer of the rectum which
was occluding the lumen of the bowel. This latter
fact she realized all too well and also that she was
starving on the diet allowed herself (Fig. 1.)

We suggested: 1. Exploratory laparotomy, at

which time the bowel
would be opened and
an abdominal anus or
a temporary inguinal
colostomy provided, de-
pending upon the con-
ditions found within
the abdomen. 2. If at
this operation it was
thought feasible to re-
move the tumor later,
that such procedure
would be recommended
in two weeks, when
she would be stronger
than at present. The
patient accepted opera-
tion.

The abdomen was
opened with a long
median incision
through the linea alba, extending from below the
umbilicus to close to the symphysis. A liberal
opening was necessary to allow working space.
The descending colon was palpated and found
filled with hard fecal masses about the size of

Fig. 3. — Rectum dissected free
and the levator ani muscle di-
vided and held by clamps.

walnuts. No mesenteric glands were palpable, and
no evidence of cancer was found in the descending
colon. The liver was also found smooth, of nor-
mal size, and without metastasis. From these
findings it was decided to excise the neoplasm, but
because of its extent did not seem possible to bring
down the sigmoid and
reestablish the anus at
its normal location. An
abdominal anus was
therefore decided upon.

Two weeks of con-
valescence were al-
lowed, during which
time intensive feeding
was encouraged. The
bowel w^as emptied and
the toxemia relieved.
T!:e patient quickly
rebounded from her
depressed condition and
was in an entirely more
hopeful condition when
excision of the rectum
was recommended. She

then received the usual pic. 4.-Tumor dissected tree,

preparations for a Vag- gasped by intestinal damp and
4 ^ * excised. •

nial operation and was

placed in the exaggerated lithotomy position, the
hips slightly raised. A final examination was m^ide
under anesthesia arid the tumor was easily mapped
out by way of the vagina. It began just above
the internal sphincters and extended up behind the
cervix, but was free from both the uterus and
sacrum and was. movable in the pelvis. The peri-
neum and vagina were
cleaned once more. The
rectum below the neo-
plasm was swabbed
with hydrogen perox-
ide, dried with swabs,
mopped with alcohol,
again dried, and then
filled with a gauze plug
to otclude its lumen
and fill it out, thus
facilitating the subse-
quent dissection. The
vagina was held widely
open with broad , re-
tractors, the cervix held
up with a vulsellum and
a transverse opening in
the vaginal wall made
into the Douglas pouch.
The posterior vaginal

wall was then incised Fig. 5.— Closure of the peri-

i-^r^rr^ ^a^,,^-^ +^ wound alter the stump of

irom ine cervix tO__£ne ,he bowel bad been brought down.

fourchette, and the in-
cision carried across the perineum to within a half
inch of the anus, and a circular incision made around
the anus. By blunt dissection laterally the vagina and
perineal body were reflected from the diseased rec-
uim (Fig. 2). As we reached the lateral borders of
the rectum the levator ani and transverse perineal

January 1, 1921.]

VAX HOOK: COLON INJURY IN NTlPHRECTOM)

23

muscles were exposed and grasped with long forceps
before cutting from the rectum (Fig. 3). These
muscles contain the superficial and transverse peri-
neal and the inferior hemorrhoidal arteries which
will cause sharp hemorrhage unless seized before
being cut. The number of these vessels is some-
what inconstant, and instead of there being one
inferior hemorrhoidal artery, two or three small
vessels may arise from the internal pudic. There-
fore, active bleeders are to be looked for at all times
and picked up as found. The small vessels and
oozing are controlled by hot compresses held by the
assistant. There need be very little loss of blood.

Beyond these muscles the dissection was quickly
accomplished through the fatty tissues until the
rectum lay wholly exposed except for its posterior
attachments, the mesorectum and the rectococcygeus
muscle. These attachments are firm and should be
cut free with the scissors rather than torn away by
blunt dissection, because tugging or dragging upon
the sacral sympathetics increases the shock of the
operation.

The rectum was now grasped in the left hand, the
fingers working down behind sought the attachments
and the curved scissors in the right hand clipped
each as met ; thus quickly cleaning out the hollow
of the sacrum, taking with the mass all fat and
lymphatics. By this technic the whole field of
operation was always in sight, and the excision
quickly and completely accomplished. (Fig. 4.)
There was no dragging on the mesentery while
trying to find an evasive brand that prevented
prolapsing of the tumor. Traction on the mesen-
tery while dissecting out the neoplasm causes much
shock.

The tumor being removed, all bleeders were
ligated and the oozing controlled with a few hot
compresses. Closure of the wound was afifected
with catgut sutures, uniting the post cervical gap.
When the levator ani muscle and the fascias were
reached the clamps holding the muscles on either
side were drawn together and the severed muscle
united with mattress sutures of No. 2 catgut. Below
this level the w^ound was closed with deep sutures.
Drainage was provided from Douglas pouch into
the vagina and also from the hollow of the sacrum
out at the perineum.

30 North Michigan Avenue.

COLON INJURY IN NEPHRECTOMY.
By Weller Van Hook, A. B., M. D.,
Chicago.

The sigmoid and the splenic flexures of the colon
are not far from the surgical route to the left kid-
ney. The retroperitoneal tissues about the kidney
may become agglutinated to the bowel and may hold
the colon down near the kidney. If the kidney
becomes enlarged or sacculated it may contact the
splenic flexure. In such a case injury to the colon
may take place during an operation on the kidney.

Case. — A patient with chronic and acute intes-
tinal obstruction came under observation a few
months ago. She was so distended, poisoned, and
weak that a cecal fistula had to be made to give

temporary relief. The history included the state-
ment that a Polish surgeon had removed her left
kidney aboi t two years before, and that a fecal
fistula had )een left. This fistula gave relief from

Fig. 1. — ^After Hildebrandt. Note that the splenic flexture re-
treats from the anterior part of the abdomen and rests almost upon
the kidney. A, transverse colon; B, beginning of jejunum; C,
splenic flexure; D, cecum; E, bladder; F, rectum; G, sigmoid flexure.

discomfort when patent, but, when it closed, great
distress from bowel distention occurred. On the
occasion when she was seen with Dr. Beseler, who
called me in the case, she suffered from acute in-
testinal obstruction apparently due to scars about
the bowel at the site of the old nephrectomy.
After the patient had entirely recovered from the

Fig. 2. — The point of almost complete occlusion of the colon is
seen; and above is shown the arrangement of the coils of the colon
so that the fecal current is accommodated after anastomosis.

intestinal obstruction, attack was made upon the
real cause of trouble. The old nephrectomy wound
was opened and extended downward, when it was

24

KNOPF: THE SOUL OF THE CONSUMPTIVE.

[New York
Medical Journal.

easily seen that the splenic flexure was bound down,
damaged and occluded as suggested in the picture.
The bowel evidently had been caught in the clamp
used to compress the kidney stump. Since there
was no active disease at the site of occhision, noth-
ing was done at the immediate point of injury, but
the bowel above was joined by anastomosis to the
descending colon below. This procedure, colocol-
ostomy, resulted in complete and satisfactory re-
establishment of fecal circulation.

CONCLUSIONS.

1. Injuries of the left colon take place readily
when left nephrectomy is practised.

2. Nevertheless, damage to such an extent that
intestinal obstruction occurs must be rare and the
result of gross carelessness.

3. In acute intestinal obstruction life is less likely
to l)e sacrificed in most cases if a fecal fistula is
established at the cecum for a few days. This tides
the patient over the toxic period.

4. Colocolostomy satisfactorily reestablishes the
fecal current, making it unnecessary to work at the
site of scar contraction where wound infection from
the bowel can occur so easily.

31 North State Street.

THE SOUL OF THE CONSUMPTIVE.

A P-lca for Justice*

By S. Adolphus Knopf, M. D.,
New York.

We all know something about the physical suffer- '
ings of the consumptive caused either by his tuber-
culous lungs, throat, or other organs which may
have been attacked by the germ of the disease.
We have heard his nerve racking cough, his hoarse,
often scarcely audible voice, observed his gasping
for breath, and know that he has pain in his chest,
even when at rest, or on swallowing food if his
throat is involved. We have felt his feverish hands,
noticed his parched tongue, and sympathized with
him because of these and many other distressing
symptoms indicative 'of physical suffering.

I (|uestion, however, if many of us fully realize
what the consumptive, rich or poor, young or old,
suffers in mind and soul, beside his physical pains.
We assert that tuberculosis, which is only another
name for consumption, is a preventable disease. The
late King Edward of England once said to a delega-
tion of tuberculosis workers: "If, as you say, tuber-
culosis is preventable, why not prevent it?" This
same question the rich or well to do consvmiptive
may have asked himself, or may be still asking it.
But before answering, I should like to ask him
what he ever did in life to prevent the disease
before becoming ill himself? Perhaps he never
thought of his employees or of the thousand others
who were working in ill ventilated workshops with
no dust consumers, and living in dark and dreary
tenements or insanitary individual dwellings where
tuberculosis had become a house disease. Perhaps
he never thought of having the men and women
working for him examined periodically so that any
case of tuberculosis among them might be detected

•Address delivered by invitation before the Christmas .Seal Cam-
paign of the New York Tuberculosis Association, December 1, 1920.

and the other still healthy employees prevented
from becoming infected. It may never have oc-
curred to the rich employer, now a consumptive,
that when still at the head of his business, he should
have seen to it that any one of his employees who
had been found afflicted was cured by being taken
care of at the right time and in the right place, and
not as Dr. Pryor so well says, at the wrong time
and in the wrong place, when it was too late to
accomplish a cure.

Such thoughts will cause the well to do consump-
tive suft'erings which are difficult to describe.
While his physical pains and discomfort, thanks to
his abundant means, can be lightened, this suffering
of the soul, because he failed to do his duty toward
his fellowmen, many of whom have now become
his fellowsufferers, becomes more intensified as" the
disease progresses. It is all the more present in
his mind because he knows that the suffering of
the .poor consumptive in both mind and body is a
tliousand times more intense than his own. The
physical sufferings are alleviated in his case by a
sojourn in a health resort, a costly private sana-
torium, or a luxurious home where the sanatorium
treatment can be carried out under the watchful
care of a skilled specialist; the poor consumptive,
on the other hand, because of lack of sanatorium
facilities, often has to remain at home and there,
because of limited means, is deprived, if not totally
to a large degree, of the comforts and facilities
which help toward the cure. The well to do con-
sumptive may have the assurance of a cure after
a reasonable length of time, but the poor consump-
tive is far from having this absolute assurance.
He counts the days to the time when he hopes to
be able to work and be no longer a burden to his
family and the community.

I am free to confess that I do not share at all
in the opinion of a certain tuberculosis specialist
and author who, in his recent textbook, gives the
following characterization of the tuberculous patient :
"The consumptive becomes egotistical and ego-
centric. He is interested in the welfare of but one
person — himself — to the exclusion of all who have
depended on him before. He will eat costly food
while his children starve ; he will make unreasonable
demands on his relatives and friends and show no
gratitude. . . . The ascendance of selfishness plays
the most important role in the molding of the men-
tal traits of the tuberculous." I have always looked
on this statement as a veritable libel upon the char-
acter of the consumptive, if indeed he may be set
apart as having special characteristics because of
his disease. An experience of over twenty-five
years among the tuberculous poor, in humble cot-
tages and dreary tenements, in pul)lic sanatoria and
hospitals, has convinced me that the very contrary
is characteristic of the heart, mind, and soul of
the consumptive. How many times have I heard
some one among them .say: "If I only were rich,
doctor, I would know how to solve the tuberculosis
problem." I never refuse to listen to their schemes,
which are sometimes fantastic, but never egotistical.
They think of saving others even when realizing
that they cannot be saved themselves.

Tuberculosis, i)articularly of the pulmonary type,

January 1. 1921.]

KNOri-: THE SOUL OF THE CONSL'MI'Tnii.

25

attacks, principally, men and women l)ft\vccn the
ages of eighteen and thirty-five — the golden age of
youth, of love, of aspiration, of hopes, and dreams.
The most important events are often crowded into
these fifteen to twenty years which are usually
known as the best in life. To understand their
feelings, one must have had th.e sad duty of inform-
ing a young person with all life before him of the
fact that he is tuberculous, that he must for the
time being abandon all work and devote a year and
perhaps two to getting well. The young person to
whom such a declaration has been made, apparently
acts as if he or she believed in the doctor's assurance
of the curability of the disease, but the old fashioned
idea that tuberculosis is incurable still lurks in the
minds of the masses, and doubts of the curability,
in spite of the doctor's a.ssurance, will arise in the
mind of the newly discovered tuberculous invalid.
But even if he is of an optimistic disposition and
believes in tlie favorable prognosis in his case, if
he is poor or only of moderate means, has an old
father or mother, an invalid brother or sister, or
wife and children dependent upon him, his sufifering
of soul begins right then and there. He is worried
because he cannot provide for them, and not only
does the thought haunt him that his wife and chil-
dren may suffer for want of food, raiment, and
even shelter, but in addition to this there is often
in the mind of the conscientious consumptive a
fear that he may give the disease to some one near
and dear to him in spite of the precautions he tidies
to take. The social workers and auxiliaries of
such societies as are represented here tonight, con-
sider it always as one of their most important tasks
to relieve the anxiety of the patient concerning his
family by providing amply for their needs. The
consumptive's fears that he may be the source of
tuberculous infection can only be counteracted by
education imparted by the physician and the nurse.

Thus we see that the sufiferings of the consump-
tive, rich or poor, man or woman, are not confined
to the body, and alas ! this is also true of the chil-
dren. Tuberculotis disease in children is most fre-
(|uently situated in the joints and bones, and abso-
lute rest of the afflicted members of the body often
])ecomes an urgent necessity; in other words, the
child is compelled to remain still, often even con-
fined to bed. He cannot play as other children do.
When others romp around in field, in garden, or on
the streets, as they must do in our great cities for
lack of playgrounds, he can only look on. He may
not even be able to enjoy school life as others do.
and he lacks the companionship and comradeship
which makes child life so happy and delightful.
This tuberculous child suffers as much in mind and
soul, and perhaps more so, than in body.

Lastly, there is that strange disease known as
phthisiophobia, with which not the tuberculous but
the nontuberculous are afflicted. It is an exag-
gerated fear of the presence of anyone afflicted with
pulmonary tuberctilosis. This tuberculosis phobia,
or phthisiophobia, has caused and is causing more
suffering to the consumptive than it is possible to
imagine. People will object even to the presence
of tuberculosis sanatoria and tuberculosis hospitals,
and yet the safest place not to contract consumption

is in \n>\ such an institution, where ilie greatest
j)ossible care is taken with the expectoration, which
is virtually the only source of infection. Peoi)le
will not employ even the recovered consumptive and
some are afraid to touch him or associate with him.
Tuberculosis is indeed a public menace, and with
the prevalence of the disease we cannot be certain
that some day we ourselves or someone very dear
to us may not be stricken with it. And yet, there
is no more danger in association with the consump-
tive who is conscientiotts in the disposal of his
sputum than with any well person ; therefore let us
treat him kindly and considerately.

In speaking above of the rich consumptive as un-
mindful of his obligation toward his fellow suffer-
ers and fellowmen in getaeral, I do not wish to be
understood as implying that this is always the case.
There are now any number of corporations and
em])loyers of large bodies of men and women who
do look after the health of their employees, and it
has been my rare privilege to treat some wealthy
tuberculous patients whose hearts ached for. the less
fortunate sufferers among the poor and who gave
freely of their worldly goods. I know of a number
of instances among those who were hopelessly ill
where a large part and sometimes even the entire
fortune was left for the care of the consumptive
poor. They often suffer in soul because of their
inability to do more, knowing by personal experi-
ence how much is needed to combat this disease
among the i)oor and those of moderate means.

And now, having told you of the suffering of the
soul of the tuberculous rich and poor, young and
old, I come to jjlead for them — not for mercy, not
for charity, but for justice. Let the employer do
justice to his employees by periodical examinations
for tuberculosis and providing proper sanitation for
factory, workshop, and store. Let him see that the
worker found to be tuberculous receives proper and
timely treatment. Let the municipality of cities,
towns, and villages see to it that there are no in-
sanitary dwellings, and that such other in.sanitary
conditions which may predispose, to tuberculosis
may be done away with in the community. Let
every community provide sanitary school buildings
and see that the curriculum is such that the mental
training of the child is not pushed to the neglect
of its physical development.

The New York Tuberculosis Association, in co-
operation with the city's Health and Public
Welfare Departments and by its educational work,
teaches all this to our own and other muni-
cipal authorities, employers, and school boards,
and tries to prove to these latter why there should
never be a public or private school of any size with-
out some open air classes. To the people at large
it teaches that tuberculosis is a preventable and
curable disease. In its clinics thousands of men,
women, and children are annually examined, and
thus many cases of tuberculosis are discovered at
the right time and the association sees to it that
the patient is properly cared for. By its auxiliaries
to the tuberculosis clinics, it gives financial relief to
tuberculous families in distress. By its model sani-
tary workshops, its vocational training, and its
employment bureau it enables the tuberculous in-

26

LONDON LETTER.

[New York
Medical Journal.

valid, or the recovered tuberculous patient, to make
an honest living without running the chances of a
relapse.

Bearing in mind that the protection of children
from tuberculous disease and the cure of those
already afflicted is, after all, the essence of the solu-
tion of the tuberculosis problem, this association
has started a health centre for babies and parents
so that there shall be prenatal care, infant welfare
work, care of the children during their preschool
age, preventoria for children strongly predisposed
to tuberculosis, etc. In short, all that can humanly
be done to prevent tuberculosis and to cure those
afflicted with it, this association and one thousand
others throughout the United States are trying to
do. It appeals for financial help and encourage-
ment ; it appeals to all able to help in this great
crusade which has for its purpose the lessening of
the sufferings of mind, body and soul, and rendering
happy, healthy, and useful thousands of our fellow-
beings who otherwise might be doomed to be a
burden to the community and to a lingering death,
accompanied by indescribable suffering. The asso-
ciation appeals for justice to the cause of the tuber-
culous sufferers who contracted the disease by no
fault of their own. It is our duty to help them ;
let us hasten to embrace this opportunity for service
to God, country, and our fellowmen.

16 West Ninety-fifth Street.

LONDON LETTER.
(From Our Own Correspondent.)

Treatment of Patients on the Borderline of Insanity— Care
of the Mentally Deficient — Medical Education in _ Great
Britain — Cancer Research— Clinics for Mental Diseases.

LoxDON, November 30, 1920.
The treatment of insanity is now conducted upon
more intelligent lines by far than was formerly the
case. It is recognized that certain forms of men-
tal disorder, whfch not long ago were regarded as
hopeless, are amenable to proper treatment. Of
course, it is largely a question of correct diagnosis
and treating the disease while in the incipient stage.
It is only within comparatively recent times that
any provision has been made for the obsen-ation
and treatment of what are known as borderline
cases. In the Ministry of Health bill introduced
a short time ago in the House of Commons, are
new legislative proposals concerning the treatment
of incipient mental disorder. Clause 10 of this
bill deals with the treatment of incipient mental
disorders and contemplates that a person thus suf-
fering may be received in homes, institutions, or
houses. An individual may be dischaiged from
one of these places if he delivers to the superin-
tendent or other person having charge, or sends by
post to the Minister of Health, a notice in writing
that he desires to be discharged. This clause was
sharply discussed by a committee of the House of
Commons, which addressed itself to the problem
of combining treatment and freedom of personal
action on the part of the patient. In accepting an
amendment that the notice to the minister should

be one of forty-eight hours, Dr. Addison, Minister
of Health, said he wanted to have these institutions
as free as possible for the people to go out. The
forty-eight hour limit was necessary in the case of
a letter sent through the post. Lieutenant Colonel
Raw proposed an amendment to provide that in
the case of the mental incapacity of a patient, the
consent might be given by the nearest relative.
This was opposed on the ground that its adoption
might lead to abuse. A husband, for instance,
anxious to get rid of his wife, might quarrel with
her, say she was mentally unfit, and have her
placed in a home against her will. Dr. Addison
said if the clause was not amended in the way
suggested, it would shut out a large number of
shell shock cases where the sufferers in the early
days were not competent to sign their names. He
admitted that the acceptance of the amendment
might lead to an increased opportunit}' for scandals
to arise. Personally he would vote for the amend-
ment which was rejected. The clause with the
amendment that the notice to the minister should be
one of forty-eight hours was agreed to.

* * *

Under the auspices of the Central Association
for the Care of the Mentally Deficient, a conference
on mental deficiency was opened on November 25th
last at Church House, Westminster. Among the
speakers was Sir George Newman, chief medical
adviser of the Ministry of Health, who said, in part,
that the responsibility of the State lay in the duty
of finding out mentally defective children. If
money was not spent on their training it would be
spent because they would become a charge on the
State. The child's training must consist, not in
making him capable of passing an examination, l)ut
of converting him or her into a good citizen. A
resolution was passed urging legislation to enable
local educational authorities and authorities under
the Mental Deficiency Act to combine in the pro-
vision of institutions.

The problem of treating mental disorders in their
incipiency and preventing insanity as far as pos-
sible, and of so training mental defectives that they
may become useful rather than harmful, is one
that confronts every country of the world. It is
also increasing in its gravity. Unfortunately, men-
tal defectives are numerous in all civilized countries,
and are a public menace. The result of legislation
in Great Britain to offset the evil effects of mental
deficiency is a step in the right direction, and will
doubtless be watched by the governments of other
countries with the closest interest.

* * *

The matter of medical education in this country-
was made a subject for discussion at the meeting
of the British Medical Council, which opened on
November 23rd, under the presidency of Sir
Donald Macalister. Introducing a report on pro-
fessional education before the council on Novem-
ber 25th, Dr. John Yule Mackay, chairman of the
education committee, said that the undue stress
\vhich was laid on the test by written examination
frequently repeated was a weakness and source of
danger in the British educational system. The habit

Januiiry 1. 1921.]

LONDON LETTER.

27

of judging progress in study by a method which
demanded severe but spasmodic eiforts directed
toward the repetition of details often unimportant,
and usually only partially understood by the pupil,
was unfortunately growing and tended to obscure
the true purposes of education. In medicine today
the exigencies of the examination tended to dom-
inate both teaching and study.

It has long been recognized by many of those
best qualified to judge that the written examination
in all spheres of education has been abused. Per-
haps the folly of paying too great attention to
the written examination has been most in evidence
in medical education. A brilliant man, one who
imbibes his facts easily, will cram for a written
examination, pass with flying colors, and forget
a good deal of this undigested matter in a short
time. The written examination does not by any
means always constitute a reliable test of a man's
knowledge, nor, it must be added, are the questions
asked calculated in many cases to yield the best
results in tlie long run. As Dr. Mackay said, un-
important details are frequently pushed into the
foreground while really essential points are left
severely alone.

The question of written examinations in medi-
cine and surgery is one that needs discussion and
consideration in all countries and one upon which
valuable reports might be composed.

:|: * *

At the home of the Medical Society of London,
Professor J. B. Farmer, of the Royal Society of
Science, South Kensington, lectured on Some
Biological Aspects of Disease on the evening of
November 25th. He urged a more comprehensive
and thorough investigation of the cancer problem
than had so far been attempted. He asked.
Were the people of Great Britain prepared to go
on watching the daily ravages of an unsparing foe
without doing everything that was hinnanly pos-
sible to check its course? It appeared to the
speaker that the full magnitude of the task had
not been sufficiently realized. A dozen or more of
the first rate men attached to research in the diflfer-
ent relevant branches of science should be working
in collaboration, and they ought to be provided
with the means of attracting to their laboratories
a number of able research students.

Professor Farmer is perfectly right in criticising
the attitude of the British public toward scientific
research. The average man here regards the ques-
tion with contemptuous indifiference, and will not
put his hand into his pocket to assist the advance-
ment of research. He does not understand its
value and, therefore, through ignorance, depreciates
its usefulness. He requires to be educated himself.
As is truly said in an editorial in the Medical Press
and Circular for November 24, 1920, the British
people grudge the expenditure of public money on
science, and, despite the lessons of the war, that
grudging is being actively pursued. Doubt may be
felt whether Great Britain will ever understand that
a nation which lays itself out to develop science
places itself in the position of cultivating an un-
limited field of wealth. The discoveries of science

must always lead the way in the advancement of
industrial occupations. But so it is that science
is "starved," starved by the fear of money being
spent upon that which will produce unremunerative
results.

This statement emphasizes the point that the
British lack of appreciation of scientific research
and of medical scientific research in particular is
largely due to a want of comprehension of the
subject in all its bearings. If a nation is not gen-
erally healthy it cannot long be prosperous, as a
healthy nation has a manifest advantage over one
that is handicapped by disease and invalidity. The
British public must be educated to understand this
point of view before money will be given freely
in aid of medical research. However, among the
persons who should understand the situation, the
presumably educated rich, there is displayed a
niggardliness toward contributing to assist the
advancement of scientific research which is aston-
ishing. In America money is poured out without
stint to aid in the progress of science. The idea
appears to be grasped in America that money spent
on science and on medical science is money well
spent. It comes back with compound interest. To
lay bare the secrets of disease and to prevent its
occurrence is only possible with the assistance of
medical research. The country that is healthy and
has made the most intelligent use of science in
all its forms will easily be the most prosperous and
contented. Until the mass of the inhabitants
acquire a conception and appreciation of the value
of science, it cannot keep abreast of the countries
that do these things.

* * *

The problem of dealing properly with mental
disorders has been referred to already in this letter
at some length. However, as it is an extremely
important subject, it will not be superfluous to
comment upon other aspects of the matter. In
Great Britain only one hospital, the Lady Chichester
Hospital for Women and Children at Hove, Sussex,
specializes in all forms of nervous and mental
breakdown in their early stages. This hospital has
just published a short survey of its work for the
past fifteen years. It states that experience gained
in the hospital strikingly confirms the arguments
which the leading mental specialists are now urging
in favor of establishing clinics for the treatment
of such diseases in connection with the general hos-
pitals. Under the present system no hospital treat-
ment is provided for nervous and mental patients
until they have reached the certifiable, and, there-
fore, in the majority of cases, the incurable stage.
What is urgently needed is that sufferers from these
diseases should have exactly the same prompt and
easy access to treatment as the sufl^erers from any
physical disease. The treatment pursued at the
hospital was most successful, and it is stated that
it has a waiting list five times more numerous than
the patients under treatment. The psychopathic
ward as known in America is unknown here, but
great interest is now being evinced in the question,
and it appears certain that some will be established
in general hospitals in the near future.

Editorial Notes and Comments

NEW YORK MEDICAL JOURNAL

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and the Medical News

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NEW YORK. SATURDAY, JANUARY 1, 1921.

SEASON'S GREETINGS.
To our readers, contributors, advertisers, and
friends with whom we have spent the none too
short nor untroubled year, we extend our warm-
est greetings. From the signs on every hand the
immediate future seems none too lacking in the
demands it will make upon us to face stressful
situations. It is only by recognizing things as
they are and not as we would have them that we
shall be able to meet them whole heartedly and
unafraid. We extend our greetings and our hand
to you all and trust that we can go together
toward the goals of progress with the knowledge
that striving makes strength. We thank you for
your cooperation in the past. It has made the
struggle worth while. We trust that we may act
as an inspiration and make your task the more
worth while and easier of fulfillment. Let us
meet the New Year with strong hearts, with be-
lief in ourselves and one another.

MEDICINE AND AGRICULTURE.
Under the term agriculture, doctors are now to
study all that pertains to foods and breeding and
to drug production. The farmer, the veterinary,
the botanist, the chemist, will henceforward find a
place at medical meetings, for the gentle cow, the
frolicsome lamb, the silvery fish may harbor disease
in life and give it to man when dead. Plants them-
selves have foes, which make them enemies of man.
We pay highly for imported drugs which flourish
in our field. Epidemics destroy our stocks, thereby

the price of food is raised and people suffer in
health. So that the whole science of liealing seems
likely to resolve itself into the great question of
cooperation of the entire scientific world, for, truly,
no one body can be rejected without loss to the
whole.

An Indian doctor draws attention to the further
knowledge and cultivation of Indian drugs, saying
that although the British Government has acted
wisely in appointing directors, yet it would have
been better to have selected some native medical
practitioners who thoroughly know the plants and
know also their Ayurvedic materia medica. India
abounds in medicinal plants, but only comparatively
few are really known, and yet are used empirically
as household remedies. Every step and process
should be recorded in the scientific journals, meri-
torious work receiving reward, and suggestions
invited.

Veterinaries in foreign lands are forging ahead
guarding our food supplies by scientific investiga-
tions. One member of the Royal College of Veter-
inary Surgeons has been to South Africa, inoculat-
ing Mbosi cattle for rinderpest, and found laminitis
general. Tlie animals became lame, had no milk,
and wanted to lie down. Sir Arnold Theiler has
]>r()ved that Crotolaria burkeana is responsible. The
veldt is rich in leguminous plants, and game of all
kinds assemble for feeding during the dry season.

Even camels are being studied, as 86.52 of those
on service in Mesopotamia died, but it must be
remembered that special knowledge is required and
few of the keepers had ever seen a camel outside
a zoo. Two men in India are endeavoring to fight
the Syngamus laryngeus in Indian cattle and buf-
faloes. The parasite is foimd attached to the
interior of the larynx; there are symptoms of cough-
ing, loss of condition, and speedy death. Ten or
twelve pairs of worms on the mucous membrane
of the larynx were found postmortem.

The chemists and liotanists who were in govern-
ment service during the war are now making wide
voyages in little explored places to gather and test
proposed substitutes. One man we know went from
London away to the forests of Buenos Aires,
another to the remote parts of South Africa.

The work of the bacteriologist is still conquering.
Slowly, slowly, the unknown evils which devitalize
the grand tree and the ponderous buffalo, man in
his prime, the cradled baby, are discovered, and will
utterly be destroyed when the great army of co-
operative research is no longer merely an idea..

hiiiuaiN 1. 1921. J

EnirORIAL AKTICI.liS.

29

TILANSFUSION OF HLC )()!).

It is now a truism to state tiiat transfusion of
blood established its value during the war. It cer-
tainly did so, and, of course, new and more effective
methods of carrying out the x^rocedurc were evolved.
Although no method can be said to be unsusceptible
of improvement, it can be stated unreservedly that
saTisfactory methods of blood transfusion have been
thought out and practised. At a meeting of the
Edinburgh Mcdico-Chirurgical Society, held on
November 4, 1920. Mr. J. M. (Jraham read a ])aper
(in transfusion of iilood, basing his observations on
seventy-five cases. He pointed out that the first
question is the choice of a suital)le donor, and that
in all cases, except in newborn infants, jirelim-
inary tests must be done to preclude the risk of the
patient's serum hemolyzing the donor's corpuscles.
This is a very important point and should be ascer-
tained definitely before transfusion is commenced.
As hemolysis is always preceded by agglutination
of the corpuscles, the patient's serum is tested to
find out if it agglutinates the donor's corpuscles.
If it does not do this the donor is satisfactory.
There is no need to describe the technic of this test.

As for the method of transfusion, Graham agrees
with the majority of those who have had experi-
ence, that the simple.st method is hy the. use of a
solution containing such a salt as .sodium citrate,
of which two per cent, is required to prevent clot-
ting. He uses a three and eight tenths per cent,
solution, which, when diluted with nine volumes
of blood, gives a strength of thirty-eight hundredths
per cent., thus allowing a small margin on the
right side. Graham thinks this solution is quite
as effective as whole blood in cases of hemorrhage,
but there is a greater tendency for a reaction to
occur. He does not recommend the direct arm to
arm method, as it is difficult and. necessitates the
sacrifice of a radial artery, and also the volume can-
not be measured. In his opinion the chief indica-
tions for transfusion are serious hemorrhages, espe-
cially in the absence of complications, and when the
bleeding point can be controlled. In hemorrhages
with slight shock it is also indicated, and also as
a preventive of shock in operations on anemic
patients. In cases where shock is marked, results
are unsatisfactory. In chronic anemia, results are
doubtful ; but when other treatment has failed and
there is no discoverable primary disease to prevent
recovery, it should be tried. In malnutrition of in-
fants, especially where the infant is reduced to the
stage of collapse, there is often striking benefit seen,
but results as a whole are doubtful.

Perhaps the best results from transfusion are
witnessed in pernicious anemia. Graham states that

out of tliirlx -eight ca^es there was delinile imi)ri)\e-
menl in twenty-one. a very satisfactory outcome.
Results were better when whole blood was given.
In these cases transftision was recommended because
the symptoms were progressive or stationary, in
spite of the usual treatment, and because the patients
were in a critical condition. The signs of imjirove-
ment lasted a variable time, but the blood counts
never returned to normal, and the expectation of
life for a few months was small. The chief value
of transfusion in this disease is that it might stimu-
late the marrow^ in stich a way that a patient toler-
ates arsenic better and improves until a subsequent
relapse occurs.

In the main Graham's views are in accord with
others who have had a good deal of experience
of transfusion during the war. It should be borne
in mind that Robertson, of Toronto, was a pioneer
in evolving new methods of blood transfusion, and
that Primrose, also of Toronto, did much good
work in the same direction. Transfusion was one
of the surgical procedures which was greatly ad-
vanced through war experience. Valuable knowl-
edge was gained which will undoubtedly be put to
good u.se. and especially so in industrial surgerv.

PHYSICIAN AUTHORS: DR. JOHN
BROWN

Of all the literary canines that go yapi)ing and
yelping through the pages of literature, right away
back to the m}thical hounds which Diana kennelled
on Olympus and down to the present day assortment
of magazine and twelvemo collies and terriers, none
is more famous that Dr. John Brown's old, grey and
brindled mastiff, Rah, "as big as a Highland bull"
but much more lovable. The story of Rab and His
Friends is known wherever English is spoken and
holds its own as one of the finest dog stories ever
writteti. There are many who would call it the
finest. It is part of what Andrew Lang called "the
light but imperishable literary baggage" which Dr.
Brown left to posterity, for his fame greatly ex-
ceeds the measure of his literary output. It is built
upon a few essays and sketches, but chiefly it rests
upon the story of Rab. Rab and His Friends was
published first in 1859. Brown wrote it between
twelve and four of a summer morning, it is said.

Ye stapped your pen into th' ink
.\n' there wa.s Rah,

as Robert Louis Stevenson wrote in his poem. "To
Dr. lohn Brown." Stevenson was one of the many
great ones of the earth who have been fond ol
Rab. It is doubtful if any other short story ever
elicited as much praise from so many eminent ad-
mirers. Their tributes would fill a large book.

30 EDITORIAL

Dr. Brown's small literary output was due to
the fact that most of his life and energy were given
over to the practice of medicine. He was the most
eminent physician of Edinburgh of his day, and
"thoroughly devoted to his profession." J. Taylor
Brown, writing in the Dictionary of National Bi-
ography, points out that it is doubtful whether
Brown, for all his wide culture, would ever, but
for his love of his profession, have been induced to
appear before the world as an author. His first
volume, Horce Subscciva is almost exclusively de-
voted to subjects bearing on the practice of med-
icine, such as the importance of the wide general
culture of a physician, the distinction to be always
kept in mind between medicine as a science and
medicine as an art, the necessity of attending to
Nature's own methods of cure and leaving much
to her recuperative powers rather than to medical
prescriptions, and, in general, the value of presence
of mind in a physician.

Horce Subscciz'cc was one of three volumes that
comprise Dr. Brqwn's literary output. We are told
that editors and publishers had to importune him to
write, and that his answer invariably was that one
should not venture to publish anything "unless he
has something to say and has done his best to say it
right." "Herein lay the secret of his writing so little
and of the surpassing charm of what little he did
write," says Chamber's Cyclopedia of English Lit-
erature. "Dogs, children, old world folks, friends
gone before and Lowland landscapes — these were
the subjects he wrote on best. Humor is the chief
feature of his genius — humor with its twin sister,
pathos. We find them both at their highest per-
fection in his sketches Rab and His Friends and
Pet Marjoric. Writing of nothing that he did not
know, he wrote of nothing he did not love, at least
of nothing that he did not greatly care for — hence
both the lucidity and the tenderness of his essays.
They rank with Lamb's, and with Lamb's alone in
the language."

In recent months there has been renewed interest
in his sketch of Pet Marjoric, due to the somewhat
sudden craze for the writings of child literary prod-
igies that has sprung up since Daisy Ashford burst
in on an unsuspecting public with The Young Vis-
iters. Pet Marjorie, whose full name was Marjorie
Fleming, before her death in 1811 at the age of
eight, had written reams of journals and poems, in-
cluding a two hundred line epic on Mary, Queen of
Scots. She and Sir Walter Scott were great chums.
Her biography, written for the Dictionary of Na-
tional Biography by Sir Leslie Stephen, is, as Sir
Leslie said, "probably the shortest to be recorded in
tliese volumes, but she is one of the most charming

ARTICLE.S. [New York

Medical Journal.

characters." Equally charming is the essay Brown
wrote of her.

Dr. Brown was born at Biggar, Lanarkshire,
Scotland, on September 22, 1810, and died in Edin-
burgh on May 11, 1882. He attended a private
school at Edinburgh from 1822 to 1824, then spent
two years at the Edinburgh high school, after which
he attended Edinburgh University, where he began
the study of medicine in 1827. From 1828 to 1833
he was apprenticed to Dr. James Syme, one of the
most famous surgeons of his day, and obtained his
medical degree at the university in 1833. He spent
the rest of his life in Edinburgh in the practice of
medicine. In his medical capacity he is said to have
been remarkable for his close and accurate observa-
tion of symptoms, his skill and sagacity in the treat-
ment of his cases and his conscientious attention to
his patients. "He was a man of rare sweetness of
disposition and charm of manner," says Andrew
Lang. "I have never known any man to whom
other men seemed so dear — men dead, men living.
He gave his genius to knowing them, and to making
them better known, and his unselfishness thus be-
came not only a great personal virtue, but a great
literary charm."

THE TUBERCULOSIS PROBLEM OF TH^
PRESENT DAY.
Because before the war the tuberculosis mortality
had been on the decrease in nearly all civiHzed
countries, and particularly in our own, there is no
doubt that its present increase throughout Europe
and to some extent also in our own country is a
consequence of the war. In Central Europe the
situation is appalling and Mr. Hoover is asking
for $33,000,000 to feed the 3,500,000 starving children, many of whom, by reason of underfeeding and privation, are already tuberculous or will be- come so if succor does not come soon. Mr. Hoover wishes to devote$10,000,000 of the $33,000,000 to medical relief. It is our earnest hope that this good and great man will get all he asks for to accomplish what may be considered the greatest humanitarian work ever done by the American people. However, we must not forget that here, too, we have a tuber- culosis problem toward the solution of which we must devote our energies. In the United States it is perhaps not so much malnutrition and want of proper clothing as the congestion resulting from lack of housing facilities in our large cities which is responsible for the increase of tuberculosis. The congestion today in our own city, particularly in the tenement house districts, is something fearful. Total ignorance of sanitary regulations among a large class of the population in the congested dis- January 1, 1921.] EDITORIAL ARTICLES. 31 tricts adds to the spread of the disease. Aside from this, we are in midwinter and the problem of un- employment on an unprecedented scale is slarinj;- us in the face. In Dr. Knopf's article, entitled The Soul of the Consumptive, which appears in this issue, a graphic description is given of the mental sufferings of con- sumptives, the rich and poor alike. When we add to this the physical sufferings of the tuberculous invalid, it certainly must be obvious that there is much work to do yet for the housing, general social betterment and education of the masses. The New York Tuberculosis Association is in great need of funds to do its work in cooperation with the health and public welfare departments of this city. This association helps to maintain our tuberculosis dis- pensaries, has a model sanitary workshop for voca- tional training, maintains a health centre for babies and parents, coordinates other charitable institutions in relief work, and gives financial aid to families in distress. The New York Tuberculosis Association has for its president Dr. James Alexander Miller, for its secretary Dr. Nathan E. Brill, for its treas- urer Mr. Thomas W. Lamont, and for its director , Dr. John S. Billings, with offices at 10 East Thirty- ninth Street, New York City. On the board of directors are such distinguished medical and social workers as Dr. and Mrs. Hermann M. Biggs, Dr. John W. Brannan, Dr. Royal S. Copeland, Dr. Haven Emerson, Mr. Homer Folks, Dr. Lee K. Frankel, Mrs. W. E. S. Griswold, Mrs. James E. Newcomb, Miss Blanche Potter, Dr. George M. Price, Mr. Lawson Purdy, Mr. Fred M. Stein, and Mrs. William G. Willcox. The national association, of course, has a still greater field of usefulness than the local association. Besides coordinating all the state and local associa- tions and other agencies in the fight against tuberculosis, this association has a publicity bureau and a number of traveling exhibits, publishes a sanatorium directory, promotes needed federal legislation and health programs, and standardizes all forms of antituberculosis work. The work of the association is accomplished through correspond- ence, field work by staff representatives, annual meeting^ of sectional conferences, conduct of interstate campaigns, such as the Red Cross Christmas Seal sale, tuberculosis week movement, general publicity, publication of research studies, literature, bulletins, and, in general^ by serving as a clearing house for information and advice on every phase of the tuberculosis problem. The National Tuberculosis Association also publishes a most reliable scientific journal. A review of its Novem- ber number appears in our present issue, which speaks for itself. The name of the journal is the American Reviezv of Tuberculosis. The officers of the National Tuberculosis Association are Dr. Gerald B. Webb, of Colorado Springs, president; Colonel George E. Bushnell (retired), of Bedford, Mass, honorary vice-president; Dr. George M. Kober, of Washington, D. C, secretary; Mr. Henry B. Piatt, of New York, treasurer; Dr. Charles J. Hatfield, of Philadelphia, managing director; Dr. Philip P. Jacobs, of New York, publicity director; Mr. Frederick D. Hopkins, of New York, adminis- trative secretary. The board of directors is com- posed of leading specialists and social workers of nearly every State in the Union. * The office of the association is located at 381 Fourth Avenue. Any reputable physician in good medical standing and any layman honestly interested in the control of tuberculosis and is not engaged in an enterprise foreign to the ideals of the association is welcomed to membership. The dues are five dollars a year. Members of the association are entitled to receive a number of valuable publications, including the Journal of the Outdoor Life, a monthly magazine and the official organ of the association ; the Monthly Bulletin of the association, and various other inter- esting and instructive publications which are issued from time to time, such as Transactions, Tubercu- losis Directory, and various special volumes and studies. Members are also entitled to receive the American Review of Tuberculosis, at the reduced price of two dollars a year. BARBERS, EAST AND WEST. Dr. Arjan Das, in the Indian Medical Journal. deplores the fashion for cropped hair which is gain- ing in India. He says hair is an additional ornament for a rich woman, and often the only ornament of the poor. "In man if the hairs are well combed, oiled, and parted, either in the centre or side of head make one look like a gentleman." The shaving of mustache and the epilation of nasal hairs is bad, as they prevent the introduction of even minute particles of dust entering the nose. Worse still is the increasing practice of shaving" the beard as this protects the throat and hinders dental neuralgia. If shaved, the man looks like a eunuch. "Now I see boys and young men with beard and mustache shaved, and they call this Curzon fashion. Shaving has become the fashion both with Hindus and Mohammedans, though a bearded man among the latter is still shown more respect, and the mustache is clipped only as a religious rite." THE INDEX. The index for the volume covering the past six months will be published separately. A copy will be mailed to any. of our readers who will write for it. 32 XEirs ITEMS. IN' w York Medical Journal. News Items. Beer for Medicinal Purposes. — It is reported that a Wisconsin brewery has asked permission to make beer for medicinal purposes. The request has been refused for the present. Gift to Vienna Charities. — Richard Strauss, the composer, has ])laced a part of the proceeds of a successful Soutli American tour at the disposal of Viennese charities. The amount is estimated at tliree million kronen. Theatrical funds are to benefit, but most of the money is to be used to feed the children. State Clinics for Mental Disease. — Three new state hospital clinics for mental disease have been established recently, increasing- the total number to forty-one. One of these clinics is at Warsaw, Wyoming County, one at Glens Falls, and one in Geneva. The reestablished Peekskill clinic of the Hudson River State Hospital held its first session on November 5th. Medical Director of League of Red Cross So- cieties. — Colonel 1'. F. Longley, chief of the De- partment of Sanitation of the League of Red Cross Societies, has been appointed acting general medical director of the league following the departure of Dr. Hermann M. Biggs, health commissioner of New York State, who had temporarily assumed the duties of general medical director. Dr. Mosher Sues Nassau Electric Railroad. — ■ Dr. Burr Burton Mosher, of 11 Schermerhorn street, Brooklyn, has brought suit for$150,000
damages against the Nassau Electric Railroad Com-
pany for injuries he received on February 22d,
last, when his motorcar was struck by a trolley at
Atlantic and Flatbush avenues. It is alleged that
the injuries compelled the doctor to abandon his
activities, which had been numerous and varied,
despite his sixty years.

Urological Department Opened at New York
Hospital. — The New York Hospital announces
the opening of the Urological Department in ac-
cordance with the terms of the will of the late
James Buchanan Brady. Temporarily indoor
quarters have been assigned to the department in the
hospital at 8 West Sixteenth street. The out pa-
tient clinic will be carried on in the out patient
department of the hospital at the following hours :
men: daily, 10 to 11 a. m. fexcept Wednesday)
daily, 7 to 8 p. m. (except Tuesday). Women:
Tuesday, 7 to 8 ]). m., Wednesday. 10 to 11 a. m.

Insanity Damage Suit. — Dr. William B. Gib-
son and Dr. Walter Lindsay are the defendants in
a $1,000,000 damage suit brought by Ada M. and Phoebe K. Brush, formerly of Huntington, L. I., who were released from the State Hospital for the Insane at Kings Park, last March. The physicians signed the papers committing the women to the asylum, where they were confined ten years. The complaint alleges that the women were not insane when committed. Each of them is demanding$250,000 damages from each of the ])hysicians.
The actions are brought in the Supreme Court of
Westchester County.

Harvey Society Lectures. — Dr. Alfred F. Hess,
of the New York University and Bellevue Hospital
Medical College, will deliver the fifth Harvey Society
Lecture at the New York Academy of Medicine,
Saturday evening, January 15th. His subject will
be Newer Aspects of Some Nutritional Disorders.

Rockefeller Foundation Grant for Cincinnati
University. — The general education board of the
Rnckfeller Foundation has ofifered to contribute
$700,000 to the Medical College of the University of Cincinnati, on condition that the balance of$400,000 to complete the $2,000,000 endowment fund be subscribed. To Fight Antivaccination. — A public meeting will be held in Borough Kail, St. George, Staten Island, Friday evening, January 7th, to fight the recent movement against vaccination. Among the speakers will be Dr. Royal S. Copeland, health com- missioner, Dr. Lelsnd E. Cofer, health officer of the Port, Dr. Walter H. Park, director of health department laboratories, and Dr. S. Dana Hubbard, of the health department. Borough President Van Name will preside at the meeting and the Medical Society of the County of Richmond will attend in a body. A Dinner to Dr. Keen. — A dinner, followed by a reception, will be given to Dr. W. W. Keen of Philadelphia, by his friends and as.sociates, on his eighty-fourth liirthday, Thursday evening, Janu- ary 21st, at the Bellevue-Stratford Hotel. Many distinguished men, prominent not only in medicine but in military, diplomatic, educational, political and religious circles, will be present to participate in this tribute to Dr. Keen, the dean of American surgeons. A bronze bust of Dr. Keen, modelled for the occasion by a noted sculptor, will be pre- sented on behalf of those participating. Sheepskin Coats for Tuberculosis Patients. — The United States Public Health Service has pur- chased 2500 sheepskin lined coats for use in its tuberculosis hospitals. Clothed in these wind proof coats, which extend to the ankles, ex-service men are expected to enjoy the sunshiny winter days while taking the cure in their reclining chairs dur- ing the rest hours at Uncle Sam's various sanator- iums. A sufficient number of these coats have been sent to all the sanatoriums, both in the arid south- west and in the A.sheville .sector, as well as others throughout the country. Even those in southern California have not been neglected, as the days are sometimes chilly there. Suicides Follow Famine in China. — According to cable dispatches from Peking, starvation, suicide and murder are beginning to take their toll from China's famine sufl^erers. Efforts are beifig made to aid the unfortunates, but the workers are handi- capped by lack of funds and an insufficient number of relief workers, so they can .save but a small proportion of the millions who are doomed to die. The distress in China is well illustrated by the fact that at the French Hospital at Chengting-su, a handful of nuns are sheltering 2,056 aged famine victims in a space normally u.sed by fifty. The nuns are aided by the strongest of their charges in building shacks for the fast rising tide of famine sufferers. January I, 1921.] NEllS ITEMS. 33 Report of Jewish Hospital, Brooklyn. — The annua! report of the Jewish Hospital of Brooklyn for the fiscal year ending Octoher 31, 1920, shows an increase in the number of patients treated in the hospital over the previous year. In 1919, 5,928 patients were treated and in this report 6,005 pa- tients are listed, with an average of 232 patients a day and 85,156 days of treatment. The ambu- lance' responded to 1,419 police calls. In the dispen- sary the number of patients dropped from 40.058 in 1918, to 34,751 for this year, largely due to the discontinuance of the orthopedic clinic. Prohibition Gets Credit for Decrease in Insan- ity. — According- to Dr. Horatio M. Pollock, chief statistician of the State Hospital Commission, since the advent of prohibition there has been a consider- able decrease in the number of persons committed to State Hospitals for the Insane. Data gathered by Dr. Pollock show that a considerable percentage of the number of insanity cases in the state were caused by the excessive use of alcohol. In 1909, for instance, 10.8 per cent, of the persons com- mitted that year had become insane from alcoholism; this year the percentage of insanity cases caused by alcohol was only 1.9. Kings County Medical Society. — At the annual meeting of this society, lield Tuesday evening, December 21st, the following officers were elected: President, Dr. Arthur H. Bogart ; vice-president. Dr. Frank D. Jennings; secretary, Dr. Lewis H. Addoms ; associate secretary. Dr. Thomas M. Bren- -nan ; treasurer. Dr. Robert L. Moorhead ; associate treasurer. Dr. Alfred Bell ; directing librarian. Dr. William Browning; trustee, Dr. William Linder ; censors. Dr. John G. Williams, Dr. O. Paul Hump- stone, Dr. Robert Barber, Dr. H. T. Lang worthy. Dr. William H. Bayles. The following were elected delegates to the State convention: Dr. Russel S. Fowler, Dr. Charles E. Schofield, Dr. William F. Campbell, Dr. S. J. McNamara, Dr. William Linder, Dr. Edwin A. Griffin, Dr. Arthur H. Bogart, Dr. John J. Sheehv, T)r. Elias H. Bartley, Dr.' Walter D. Ludlum, Dr. Robert E. Coughlin, Dr. Calvin F. Barber, Dr. Roger Durham. Medical Unit for Eastern and Central Europe. - — Dr. Harry Plotz, medical adviser of the Jewish Joint Distribution Committee, will sail Wednesday for Europe to direct an overseas medical unit of tv.'enty American specialists, sanitarians, dentists ■and pharmacists. The unit will serve for one year in the war stricken countries of Eastern and Central Europe, and will sail about January 15th. The unit will furnish medical supplies and surgical instru- ments to local doctors and hospitals, who now lack everything and as a result are helpless to combat the diseases sweeping the countries. It will also co- ojierate with the Governments in fighting epidemics, principally typhus ; conduct educational health cam- paigns, build baths and furnish soap and fuel for them, and organize boards of health in each com- munity so that the work of the unit will go on after it leaves Europe. Thi^ is the third American Jewish Relief unit sent to Eastern Europe within a year by the committee. An appropriation of '$2,000,000 for the unit's work has been made.

Recurrence of Influenza Epidemic Uncertain.
— Surgeon General Hugh S. Cumming, of the United
States Public Health Service, says that while it
cannot be definitely foretold whether there will
be another epidemic of influenza this winter, it is
his belief that even .should it become prevalent here
and there it would not assume the epidemic pro-
i)ortions of the past two years, nor would it rage
in such severe form. As a result of careful analyses
of the epidemiology of influenza it may be stated
that an attack of influenza appears to confer a
definite immunity to subsequent attacks, lasting for
several years.

Meetings of Local Medical Societies. — The fol-
lowing medical societies will meet in New York
during the coming week :

AIoND.w, January jrd. — Clinical Society of the New-
York Polyclinic Medical School and Hospital.

Tuesday, Jmuary 4th. — New York Acadenw of Medi-
cine (Section in Dermatology and Syphilis); Medical So-
ciety of Harlem Hospital ; New York Neurological So-
ciety ; Society of Alumni of Lebanon Hospital.

Wednesday, January 5th. — New York .\ca'demy of Medi-
cine (Section in Historical Medicine) ; Bronx Medical As-
sociation : Harlem Medical Association ; Psychiatrical
Society of New York (annual); Society of Alumni of
Bellevue Hospital; Brooklyn Society for Neurology.

Thursday, January 6th. — New York Academy of Medi-
cine (stated meeting) ; Brooklyn Surgical Society (semi-
annual meeting).

Friday, January ^th. — New York .Academy of Medicine
(Section in Surgery); New York Microscopical Society;
Practitioners' Society of New York; .Alumni Association of
Roosevelt Hospital ; Gynecological Society of Brooklyn.

<> Died. Backmax. — In Philadelphia, Pa., on Monday, December 6th, Dr. Edward F. Backman, aged sixty years. BowLBY. — In Medical Lake, Wash., on Thursday, Decem- ber 9th, Dr. F. E. Bowlby, aged fifty three years. Douglas. — In Concord, N. H., on Friday, December 17th, Dr. Orlando B. Douglas, aged eighty-four years. Freeman. — In Philadelphia, Pa., on Monday, December 20th. Dr. Walter J. Freeman, aged sixty years. HoLGATE. — In Los .Angeles, Cal., on Wednesday, Decem- ber 15th, Dr. Charles E. Holgate, aged forty-four years. ■ Hellenstein. — In New York City, on Monday, Decem- ber 20th, Dr. Herman Hellenstein, aged fifty-eight years. Holgate. — In Los Angeles, Cal., on Tuesday, December 14th, Dr. Charles E. Holgate, aged forty-six years. Kerr. — In Steubenville, Ohio, on Saturday, December 11th, Dr. William B. Kerr, aged forty-three years. Labenberg. — In Richmond, Va., on Friday, December 17th, Dr. Charles A. Labenberg, aged forty-four years. Marble. — In Worcester, Mass., on Thursday. December 9th, Dr. John O. Marble, aged eighty-one years. Mills. — In Missoula, Mont., on Sunday, December Sth, Dr. William P. Mills, aged sixty-three years. Morehouse. — In West Orange. N. J., on Monday, De- cember 20th, Dr. James T. Morehouse, aged sixty-three years. Miner. — In Ware, Mass., on Sunday, December 19th, Dr. Worthington W. Miner, aged seventy -three years. Swift. — In New York City, on Monday, Decf^piber 20th, Dr. William J. Swift, aged sixty-eight years. Radebaugh. — In Pasadena, Cal., on Thursday, December 16th, Dr. John M. Radebaugh, aged sixty-nine years. Williams. — Ii) Hartford, Conn., on Tuesday. December 7th, Dr. May R. Williams, aged forty-si.x; years. Young. — In San Francisco, Cal., on Tuesdav. Nevemlx.'r 16th, Dr. William S. S. Young. Book Reviews THE HEART AXD ITS DISORDERS. The Mechanism and Graphic Registration of the Heart Beat. By Thomas Lewis, M.D.' F.R.S., F.R.C.P., D.Sc, Honorary Consulting Physician, Ministry of Pensions ; Late Consulting Physician in Diseases of the Heart (Eastern Command) ; Physician of the Staff of the Royal Medical Research Committee, etc. Illustrated. New York: Paul B. Hoeber, 1920. Pp. xx-452. Heart Troubles. Their Prevention and Relief. By Louis Faugeres Bishop, M.A., M.D., Sc.D., F.A.C.P., Pro- fessor of the Heart and Circulatory Diseases, Fordham University ; School of Aledicine, New York City, Presi- dent of the Good Samaritan Dispensary ; Physician to the Lincoln Hospital, etc. Illustrated. New York and London : Funk & Wagnalls Company, 1920. Pp. xvi-422. The Diagnosis and Treatment of Heart Disease. Practical Points for Students and Practitioners. By E. M. Brock- bank, M.D. (Vict.), F.R.C.P. Hon. Physician, Royal Infirmary, Manchester, Lecturer in Clinical Medicine, Dean of Clinical Instruction, University of Manchester. Fourth Edition. Illustrated. New York : Paul B. Hoeber, Pp. viii-158. It may seem strange to group these three books and discuss them in one review, but the practitioner who has the interests of his patients in mind will be grateful for any knowledge that will aid him in his work. It may be said in reference to some cardiac disorders that the more we know the less we understand. In a study of cardiac conditions we cannot be limited to physical signs and graphic formulae. We have many other essential things to consider. What caused the lesion ? Could it have been prevented ? What can we do to help our patient? What can he do to help himself? How much real harm has been accomplished? How much work can the patient do ? These and a host of equally itnportant questions flock to us for answer. ' * * * Some nine years ago Lewis brought out a mono- graph called The Mechanism of the Heart Beat. This w^as used for the foundation of the present book, which is a larger and a much more compre- hensive work. In it we find Lewis emphasizing his old but by no means unimportant warning, of how essential it is for the physician to use his senses in the diagnosis of the patient's condition. The patient and not the laboratory are to be the area of exploration in determining the extent of the injury. Wholesome warning and too frequently heeded. In his book he does not go into all the phases of cardiac disorders ; only certain ones are dealt with, but these with the thoroughness which marks the works of Lewis. Much new matter has been added to the original text in the first part of the book which deals with the anatomy and histology of the nodes and func- tional tissues. Here physiological principles are discussed and an explanation given for the normal pacemaker of the heart. We also have a presenta- tion of electrocardiographic deflections, and their changes in regard to their effect on either of the ventricles. This is then followed by various hypo- theses explaining the disorders of the mechanism of the heart as interpreted by the aid of the electro- cardiograph. Much experimental material has been used and examined in conjunction with the clinical records. The correlation of cardiac disorders foimd in patients and those of experimental origin is con- vincing. In this way a new light is given to the cardiac arrhythmias. Various heart blocks are analyzed ; those produced experimentally in animals and those encountered in the human. Evidence is submitted of the new rhjihm centres, both the atrio- ventricular rhythm and the much discussed idioven- tricular rhythm. Then step by step we have presented the various fibrillations, auricular and ventricular, with all their attendant variations, the heterogenic impulse, and the interrelation of extrasystole paroxysmal tachy- cardia and fil)rillation. and socalled sinoauricular heart block. A subject of widespread interest, one that demands the attention of workers in every field in medicine is cardiac syncope and unexpected death. As Lewis states the condition has for its primary cause a hidden or unrecognized defect of the nervous system, while in other cases the cardiovas- cular system is at fault and here the syncope is caused by a lack of arterial blood in the brain tissue. These cerebral anemias are then discussed at some length. Considering the difficulty in securing defi- nite evidence the situation is well w^orked out. Cases of clinical syncope are cited where the lesions were afterwards confirmed at autopsy. Standstill of the entire heart, of the ventricle, heart block and accelerated action are considered and carefully ex- plained. It may be worth while to quote from Lewis's introduction, for the following passages indicate what his general attitude is in regard to his own work : To advocate the general use of laboratory methods in- volving costly devices and time robbing technic is not my desire ; it is to emphasize the vital importance of methods of precision in progressive studies of disease while it is to be freely acknowledged that simpler methods are essential to the practice of medicine, it is clearly right to insist that in compiling reports contributory to scientific medicine precise methods are desirable. It is from this viewpoint that the example of electrocardiography is to be stressed. Inexact method of observation, as I believe, is one flaw in clinical pathologj' today. Prematurity of conclusion another and in part follows from the first Of the immediate value of graphic methods to practical medicine, it is my desire to speak but briefly. These records have placed the entire question of the human heart on a rational basis, so giving to the worker the con- fidence of knowledge ; they have influenced prognosis and have rendered it more e.xact ; they have potentially abolished the promiscuous administration of cardiac poisons, and have clearly shown the lines which therapy should follow. The new clinical observations have stimulated and directed a host of laboratory researches, anatomical, physiological, pathological and pharmacological of a valuable nature The book was written originally in the hope that it might stimulate the study of heart affections by precise methods. The author is not generally allowed to write his own review, even in part, but Lewis has so much to say that is important that in this case an excep- tion is made. There is no other worker in the field of cardiac patholog)^ to whom he can be compared. He stands alone in the portion of the field he has essayed to cover. His is the last word on the sub- ject today. Janunrv 1, 1921.] BOOK REVIEWS. 35 Bishop has tried to kill many birds with one stone. By his own confession his book is intended for "those who are sutfering from heart troubles or are interested in the subject. . . ." He wants to influence people to do those things for themselves that he lays out at the moment of the examination. He implies that the medical profes- sion has kept facts from the laity and that many more suffer from cardiac disorders than there are aware of their disease. This may be true. The belief that has been maintained among other work- ers in this field is that more persons have been treated for socalled heart disease than have it. in attempting to produce an appetizing morsel for the neurotic or the hypochondriac he immedi- ately makes his book semiscientific, which makes it of little value to the physician. It is like a child's version of the Arabian Nights Tales with all the spice removed so they may be safely read by the young folks. Now what is the situation as far as the layman is concerned? He who has no heart lesion has no need for the teachings and warnings in the book. He who has need for the teachings will not be able to handle the problems as outlined in this book. There are many problems to be con- sidered in addition to those set forth ; problems which require all the skill and training of a medical man and of a specialist, as a rule. Bishop, no doubt, is sincere when he presents his findings and he can see no reason why an ordinary reader cannot fully understand the things he has outlined in a fashion which to him seem quite clear. Yes, they seem simple to him because he has an extensive background of knowledge which he un- consciously assumes the reader also possesses. This is just what is meant by the adage that "A little knowledge is a dangerous thing." If he could sup- plement a medical course for the reader and a goodly amount of clinical experience then it might be well to give him the information — but even then, how niany physicians with all this knowledge would trust themselves to treat their own cardiac dis- orders ? This is not written in the spirit of criticism on account of any danger there might be in the num- ber of cardiac patients decreasing for the practi- tioner. Quite the contrary. Many readers of this Tiook will undoubtedly come to a physician to have their troubled minds set at rest and be told that their hearts are doing all that Nature intended them to do. The public should be educated along medical lines, but Bishop's method of approach is far from satisfactory in its results. ^ ^ Convenient and complete is the verdict of ap- proval of this fourth edition of Brockbank's manual. It is simply what it purports to be, a pocket manual for clinical reference. In its modest way it com- pletely fulfils the requirements. It contains the essence of many more voluminous books and for the student and even the practitioner it aids in recalling the elaborate discussions found in more complete textbooks. In spite of the limitations of size physical signs are grouped in a convenient ■fashion and none of the important ones omitted. THE POOR RICH. The Acjc of Innocence. By Edith Wharton. New York: D. Appleton and Company, 1920. Pp. 365. Tlie House of Lynch. By Leonard Merrick. With an Introduction by G. K. Chesterton. New York: E. P. Dutton & Company, 1920. Pp. 324. To group these two books in one review may be considered unfair to Edith Wharton, but since both have invaded the homes of the few — the rich — as settings for their stories, have flung open the doors of the new and the old aristocracies, the aristocra- cies founded on wealth, they must be content when they find themselves in the same first class compart- ments. Both of these authors, in former books, found their characters among the more lowly, if the more real, people of life. Let us now con- sider where they have reached a common ground in their invasion of the palaces of wealth ; let us see where they have diverged ; let us weigh their errors and their successes. In the case of Edith Wharton one is hardly aware that she has in the least strayed from her original surroundings. She enters the hushed drawing rooms in the town house, the doors of which are flung open for formal functions when the family name is at stake, or when there is danger of the breaking down of the formal barriers, and is quite at home. As she introduces us to one member of the family after another we have not the feeling of an invasion but we see the unfolding of characters, little souls in most instances, victims of environ- ment and a lack of initiative. They accept the orders and keep themselves away from their real wishes in accordance with the unwritten laws governing their class. Their characters are drawn with painstaking care. Her work is like delicate Chinese art, with great detail for the minute mark- ings and the same sophistication. She has shown the flimsy structure of high social life and how it shaped the course of the feeble characters caught in its meshes ; how the bolder spirits were censored ; how individualit}/ gave way to form; how charac- ters remained true to type and true to their early upbringing. She shows how the man in the story, we would call him hero but he rnight resent it, keeps away from the woman he really loves, marries a social inanimate doll, just because he has given his word. With great cleverness she reveals this apparently cold and sexless doll, the girl with the "almost boyish figure," as a subtle sphinx who, at the opportune moment, entangles him beyond all hope of recovery. She does this on various occa- sions without any sign of emotion, and it is only after her death that any inkling of it is revealed to her husband. In Edith Wharton's Ethan Tronic we see poverty keeping two lovers apart and sending them to a moral death mangled beyond recognition. They are kept as crippled prisoners for the rest of their lives under one roof within sight of each other. This is the story of two lovers and the third leg of the triangle a neurasthenic woman. Now she takes us to the rich and shows us how two lovers may be kept apart by wealth and spend a useless ex- istence, repressing their emotions, and making inarticulate cries in a most absurd sign language. 36 BOOK REVIEWS. [New York Medical Journal. In tlie case of Jltlian Proinc our sympathies are more readily enlisted, for the characters are helpless. The wife is dependent. . . . Here an adult semblance of a grown up point of view would save the day. .\ solution is not outside the realms of possibility. The situation is not hopeless, but the actors are too weak. In both instances the unloved women, the rich and the poor, made a desperate and successful effort to hold' the man — the male. In both instances they sensed the danger in an unconscious way, but they struck their blows with the unfailing precision of the hungry female spider who feasts on her unsuspecting mate. Many other points might be discussed in this work of art, for this it nmy be called with no apology. Wit and irony bring smiles and (luicken the reader's pulse. She has shown us humans in a most artificial environment and has done it so well that the most critical can find no fault. She has balanced her story with great precision, never once leading us into remote bypaths. She has con- densed her material, using no needless situations or words. The only feeble portion of the book is the epilogue, a glimpse of the newer generation with yet a glance at the past in retrospect where a more hopeful note is struck. Here we find a new code with new values based on achievement, not on family, on character not on wealth. Here she has attempted to quicken her cadence and bring things home by contrast. More convincing is the ending of the broken down family in Ethan Frame, in the tumble-down .shack with its crippled inmates. * * * Now a few words for Merrick. His is as the work of a clumsy mason. He too had a moral to teach, but in his crude way he robbed his story of any value it might have. The simple minded heroine, poverty stricken, with only two servants, and finally refusing her father's ill gotten millions ; the selfabnegation of hero and heroine ; the broken hearted, hard hearted irate parent ; much suffering, of the stage barnstorming variety ; lofty arguments ; silly chatter ; famous painting ; success ; . . . a solution of the millionaire problem; the refusal of the filthy millions. Perhaps we have an echo of the book in real life where a Boston youth has refused his father's millions. Who knows. Perhaps we will have a solution of the problem of the centralization of wealth. Perhaps the book will prove of great social worth. Perhaps. But it might be well to suggest to Merrick that he rewrite his story with more care and make his characters and the situations more in keeping with reality. THE GOLDEN BARQUE. The Golden Barque and The Weaver's Grave. By Seumas O'Kelly. New York and London : G. Putnam's Sons 1920. Pp. 253. Mortimer Hehir, the weaver, was dead, and in search of his grave, bought and never used, came Meehaul Lynskey, the nailmaker, Cahir Bowes, the stone breaker, both his contemporaries, two young gravediggers, and his fourth wife, the other three being in the new graveyard. The two old men, proud of being chosen for the search, stand in Cloon na Morav, the Meadow of the Dead. No path, no plan or map or register to guide them, the gravediggers patiently follow their search, spades ready. Confessing they have forgotten, the widow goes to ask the whereabouts of tlie grave from a bedridden ancient, one Malachi Roohan, who in his moribund condition clings to his theory that everything and everybody is a dream. He .gives wrong directions as to the grave, but, suddenly, one of the old searchers remembers it. At the finish of the opening up, the handsomer of the gravediggers is smitten with love for the widow. She saw the figure of the man spring across the open black mouth of the weaver's grave. A faint sound escaped her, and then his breath was hot on her face, his mouth on her lips. Rather sudden, all this! The descriptions of old age, old graves, old memories, are capital. It cannot be called a story, though O'Kelly crowns his senilities with a warm living kiss. The book should be read in a sun- lighted, flower decked room, for the chill damps arising from Cloon na IMorav get into one's bones. ********* It was a relief to board the Golden Barque with its genial boss, Martin Coughlan, proud of his canal boat, content with his little world, interested in but not disturbed by the mutual hatred of his two hands, Calcutta and Hike. Billy, the clown, and The Terror, a boy of eleven, his devoted admirer, make a clever chapter and brace us for another of O'Kelly's senile decayments — the Derelict, with his grizzled, long lined face, wisps of shaggy hair and head that hung level between the drooping shoul- ders. A mean, greedy crime has shrivelled him up, and makes him live near the canal in a most deserted, rheumaticky, squashy, briargrown lane. It is a relief when the boat passes his roofless house, and the story of how Martin Coughlan went on a committee and made a speech, or thought he did. cheers the reader up and makes him ready to wel- come O'Kelly's next volume. MARIE CLAIRE'S WORKSHOP. Marie Claire's Workshop. By Marguerite Audoux. Trans- lated by F. S. Flint. New York : Thomas Seltzer, 1920. Pp. 239. What of romance is to be had in the workroom of a Paris dressmaker? There is a smell of new stuflfs and of human beings, the noise of a machine, some half dozen girls, pretty, droll, sentimental, moody; a gentle patron who always pretends to be angry, and his clever, patient wife, who thinks she is making a good living when the workgirls are making one too. Nothing charms her more than when Ber^eounette, one lively worker, sings her droll little songs which cheer the whole room, and nothing alarms her more than the cold which is slowly killing little Sandrine. She sends her to her own doctor, who advises long rest and good food : "Sandrine laughed with all her heart. 'Rest? Where the deuce does he think I'm going to get that? I don't know any shop where they sell it.'" So, not knowing, tuberculosis claims the girl, who, though not married, has a lover and two children. Jaiuiarv 1. 1921.] BOOK REVIEWS. 37 a fact which liad excited no comment in the work- room, though Gabrielle, a new arrival, and preg- nant, is subjected to much chaff, even from the patron, concerning her appearance. It is awkward, too, for girls to die and to have babies when the season is at its height, and the description of over- time working is just one of those little descriptions in which the author excels : "Madame Linella must have her dress by ten on Sunday. 'Above all, make me sleeves which don't look like sleeves,' is the last demand from the imperious lady. 'The girls were all work worn,' said Marie Claire. 'I agreed to stay and help Madame Dalignac. The hours passed ; a church clock counted them one by one, without forgetting the quarters and the half hours, and the ' sounds entered the open window as if their mission were to remind us that we had not a minute to lose. The twelve strokes of midnight echoed for so long that Mme. Dalignac went and shut the window, but the hours which followed did not tire. Now and then she was overcome by sleep. She let go of her needle suddenly and her head fell forward. . . . The church clock suddenly counted three. She put down her work and got up painfully to go and make tea. ... I understood the day was breaking. Then I let my body huddle into rest and yielded unto the immense desire for a few minutes' sleep. . . . "Sleeves that don't look like sleeves." Madam worked an hour on them. . . . She gave way sud- denly, and fell on her knees. I jumped up to help, but saw she was in a deep sleep. I slipped a roll of lining beneath her head, and, fearing I should go to sleep like her, I passed a damp cloth over my face. "Sleeves that don't look like sleeves." I looked at them for a long time, then undid them. . . . Six o'clock struck. The sun, passing over the new house opposite, sought to frame itself in a window pane, and blinded me. My eyelids closed, and for a moment sleep crushed me. Then a sort of numbness seized me. It seemed to me that a great hole was forming in my chest, and there was nothing left in me but the fixed idea that the dress must be delivered at all costs before ten o'clock.' " The scene in detail, the two feverish women try- ing to keep awake, the smell of the dying lamp mingling with the stuffiness of the room, are fine portrayals of sordidness, of utter weariness. It is the same in her description of the Luxembourg on a winter morning. She even finds something interesting in the postures of the iron chairs put aside till the spring, and sprawling in grotesque attitudes. When Marie Claire takes the old sewing woman, Herminie, down to Burgundy to give the old soul a look at her native village, we share the excitement and strain to catch first glimpse of the so white, dusty roads, the vineyards, the fruit trees, but time has changed all things remorselessly, save the sun- set and the roads. You get right into the hot, hushed air of a summer evening in the vine districts, you see the full moon rising and drawing from the earth light mists, and hear the hundred voices of insects among the dusty roadside weeds, and the frogs in the half dried ponds. The end of a long day of trying to restore old scenes has wearied old Herminie sorely. "Seated on the cruml)ling stones, her hands hanging limply, and her head flung back, she was uttering a long and monotonous cry. 'Let us be off!' she cried, and dragged me toward the station." The small tragedies of seamstress life are drawn with a blunt pencil ; there is no time to stay work when Gabrielle is run over and her unborn infant killed, though all agree the fall had solved a diffi- cult question. The engagement of Marie Claire to Clement, the patron's nei)hew, lightens the gloom which lowers when a neglected illness takes the patron also. The author has a rare fashion ot making things animate and inanimate give a replica or express the idea of that which is happening in the human lives. The patron and his good wife are facing evil times : the shadow of death and debt is falling. One day a little mouse appears; the cat is fetched. The capture, the torturing play, the defiance of the tiny creature with its bleeding jaws, are an echo of the patron and his wife defying the shadows. The cat and mouse struggle accentuate, create a sympathetic realization of the human crisis. It is an enticing little story, and the reader needed no bookmark, for the end was reached before the volume was put down. THE AMERICAN REVIEW OF TUBERCULOSIS. In the issue of the New York Medical Journal of December 4th, the reviewer had occasion to speak of the Zcitschrift fiir Tubcrkulosc, now edited by Professors Kirchner, Kraus, V. Leube, Orth, Pen- zoldt, Kuttner, and Lydia Rabinowitsch. This was in reference to the first number sent for review since the declaration of the war. The Zeitschrift had its beginning in 1900 under the editorship of C. Gerhardt, Frankel, and E. von Leyden. All three of these men have since gone to the great beyond. In the year 1916, American tuberculosis workers felt the need of a scientific publication similar to the German Zeitschrift which then ar- rived very irregularly in this country owing to war conditions. Today it is the reviewer's privilege to speak of this home product, which is in every way equal, if not superior, to this veteran German jour- nal on tuberculosis science. The American Review of Tuberculosis was started in 1916 with Edward R. Baldwin, of Sara- nac Lake, as editor in chief, and Allen K. Krause, of Johns Hopkins Hospital, Baltimore, as editor. Lawrason Brown, H. R. M. Landis, Paul A. Lewis, M. J. Rosenau, Henry Sewall, and Borden S. Veeder have since been added to the editorial staff ; George Mannheimer is abstract editor. Before us is the November number of 1920. The mere men- tion of some of the contributions to this number will give an idea of the character of the publication : First Infection with Tuberculosis by Way of the Lungs, by Eugene L. Opie and Hans Andersen ; A Rontgenological Study of Influenza, with Re- covery, in an Advanced Case of Pulmonary Tuber- culosis, by Louisa T. Black and Mary Moore ; Masked Juvenile Tuberculosis, by J. V. Cooke and T. C. Hempelmann ; A Comparison of Gross Tuber- culous Lesions in Whites and Negroes, As Based 38 BOOK REVIEWS. [New York Medical Journal. on 150 Autopsies, by J. B. Rogers; Experimental Lesions of the Lungs Produced by the Inhalation of Fluids from the Nose and Throat, by W. V. Mullin and C. T. Ryder; Environmental Factors in Tuberculosis, by Allen K. Krause. It is obvi- ously impossible to review all of these articles in the limited space which can be given to it in an important medical journal, and every one of them has distinct scientific merit. The reviewer has been a sub-scriber to this periodical from its very begin- ning, and may conscientiously state that it has constantly grown in excellence. To quote again from the contents of two more of this year's issues will give a further idea of the scope of the Review. In the February number, S. Adol- phus Knopf pays a tribute to the great William Osier, an honorary vice-president of the National Tuberculosis Association, and gives a list of the great physician's contributions relating to tuber- culosis. There is a highly interesting article on Observations on the Artificial Tuberculous Infec- tion of Guinea Pigs through the Respiratory Route, by J. B. Rogers; also on Pulmonary Syphilis, by Elmer H. Funk. We may also mention An Un- usual Case of Pulmonary Tuberculosis — Terminat- ing in Spontaneous Hemopneumothorax Following Artificial Pneumothorax, by Fred H. Heise and Allen K. Krause. In the September number Horace J. Howe and William E. Lawson write on The Influence of Smallpox and Vaccination on Pulmonary Tuber- culosis ; James Alexander Miller gives us Some Problems in the Dififerential Diagnosis of Pul- monary Tuberculosis ; Francis B. Trudeau presents The Importance of Physical Signs in the Prognosis of Pulmonary Tuberculosis; B. Suyenaga, An In- vestigation of the Acid Fastness of Tubercle Bacilli, II ; Selig Simon, Artificial Heliotherapy in Pulmonary Tuberculosis ; Louis C. Boisliniere, Influenza as a Factor in the Activation of Latent l\iberculosis ; Ethan E. Gray, The Surgeon and the Consumptive ; S. W. Schaefifer, Silence in the Treatment of Pulmonary Tuberculosis. Every number contains abstracts and articles on tuberculosis and allied subjects from all the leading medical journals of the world; many articles are handsomely illustrated by original drawings or radiographic pictures. The Reviezv is issued monthly, appearing about the twentieth of the month. A volume includes twelve numbers and begins with the March number. The subscription price to members of the National Tuberculosis Association is2 a volume, with twenty-five cents
additional for Canada and fifty cents additional for
other foreign postage ; and 5 a volume to non- members, foreign postage included. Subscriptions may be sent • to Williams & Wilkins Company, Mount Royal and Guilford Avenues, Baltimore, ]Md., or to the National Tuberculosis Association, 381 Fourth Avenue, New York City. The American Rei'iew of Tuberculosis is not only indispensable to the specialist and student in tuber- culosis, but equally so to the general practitioner who must keep informed on these subjects if he desires to do his duty to his tuberculous patients and to himself. New Publications Received. [We publish full lists of books received, but we acknowl- edge no obligation to review them all. Nevertheless, so far as space permits, we review those in which we think our readers are likely to be interested.] ONE HUNDRED PER CENT. The Story of a Patriot. By Upton Sinclair. Pasadena : Published by the Author, 1920. Pp. 329. THREE PLAYS. By Brieux, Member of the French .\cademy. With Preface by Bernard Shaw. New York : Brentano's, 1920. Pp. liv- 333. contemporary RUSSIAN NOVELISTS. Translated from the French of Serge Pershy by Frederick Eisemann. Boston : John W. Luce and Company, 1913. Pp. 317. philosophic nights in PARIS. By Remy de Gourmont. Being Selections from Promenades Philosophique. Trans- lated by Isaac Goldberg. Boston : John W. Luce and Com- pany, 1920. Pp. 193. old at forty or young at sixty. Simplifying the Science of Growing Old. By Robert S. Carroll, M.D., Medical Director, Highland Hospital, Asheville, North Carolina. New York: The Macmillan Company, 1920. Pp. 147. psychopathology. By Edward J. Kempf, M.D., Clinical Psychiatrist to St. Elizabeth's Hospital (Formerly Govern- ment Hospital for the Insane), Washington, D. C. ; Author of The Autonomic Functions and the Personality. Eighty- seven Illustrations. St. Louis : C. V. Mosbv Compan^•, 1920. Pp. xxiii-762. types of mental defectives. By M.\rtin W. Barr, M.D., Chief Physician, Pennsylvania Training School for Feebleminded Children, Elwyn, Pa., and E. F. Maloney, A.B., Professor of English, Girard College. With 31 Plates Containing 188 Illustrations. Philadelphia: P. Blakis- ton's Son & Co., 1920. Pp. ix-175. the community he.\lth problem. By Athel Campbell Burnham, M.D., Health Service, Atlantic Division, American Red Cross ; Attending Surgeon, Volunteer Hospi- tal, New York City; Lieutenant Colonel, Medical Reserve Corps, U. S. Armv etc. New York : The Macmillan Com- pany, 1920. Pp. 149. textbook of nervous diseases. For the Use of Students and Practitioners of Medicine. By Ch.^rles L. Dana. A. M., M.D., LL.D., Professor of Nervous Diseases in Cornell University Medical College ; Consulting Physician to Bellevue Hospital ; Neurologist to the Aiontefiiore Hos- pital, etc. Ninth Edition. With 262 Illustrations, Including 4 Plates in Black and Colors. New York : William Wood and Company, 1920. Pp. x-655. THE radiography OF THE CHEST. Vol. I. PULMONARY tuberculosis. W'ith Nine Line Diagrams and Ninety-nine Radiograms. By Walker Overend, M.A., M.D. (Oxon). B. Sc. (Lond.) Hon. Radiologist and Physician to the Electrotherapeutic Department, East Sussex Hospital (Hastings) ; Radiologist to the City of London Hospital for Diseases of the Chest (during the war) etc. St. Louis: C. V. Mosby Company, 1920. Pp. 119. hy^giene and communicable diseases, a Handbook for Sanitarians, Medical Officers of the Army and Navy and General Practitioners. By Francis M. Munson, M.D., Lieutenant, Medical Corps, U. S. N., Retired ; Lecturer on Hygiene and Instructor in Military Surgery, School of Medicine, Georgetown University ; Formerly Instructor in Medical Zoology, Georgetown College, etc. Illustrated. New York: Paul B. Hoeber, 1920. Pp. xiv-793. THE course of OPERATIVE SURGERY. A Handbook for Practitioners and Students. By Prof. Dr. Victor Schmieden, Lately Assistant in the Royal Surgical Clinic in the University of Berlin; Professor of Surgery in the University of Halle, and Arthur Turnbull, M. B., Ch.B. (Glasg.) Lately Demonstrator of Anatomy in the Uni- versity of Glasgow. With a Foreword by Prof. Dr. A. Bier. Second Enlarged English Edition. New York: William Wood and Company, 1920. Pp. xx-349. Practical Therapeutics and Preventive Medicine A Compendium of Treatment and Prophylaxis, Original and Adapted Cholecystgastrostomy. — • Charles S. White {Surgery, Gynecology and Obstetrics, November, 1920) states tliat the operation of cholecystgastros- tomy has a definite place in surgery and the follow- ing may be concluded in regard to the operation : 1. The operation is indicated in an irremediable obstruction of the common duct or division of the duct which cannot be successfully sutured. 2. For long continued drainage in infective biliary cirrhosis it is superior to cholecystostomy in that nutrition is maintained. 3. It is not a difficult operation, being easier and safer to perform than an anastomosis between the gallbladder and the small or large intestine. 4. There is no danger of an ascending infection. 5. The presence of bile in the stomach, while unphysiological in a degree, is consistent with good digestion, and offers no argument against the operation. 6. The suture method of anastomosis is the only one to be employed. Perforation of the Cecum. — Edward H. Risley (Boston Medical and Surgical Journal, June 10, 1920) reports a case in which the special points of interest were: 1. The finding of a recently given turpentine enema free in the abdominal cavity, its entrance being through a perforation in the cecum where a completely gangrenous appendix had been sloughed off. The question may, of course, be raised as to whether or not the turpentine enema did not actually produce the perforation, or at least hasten it by several hours. 2. Recovery from general peritonitis and three secondary hemorrhages occurring as late as the eighth, seventeenth, and twenty-first days after operation. 3. Later finding of "virgin" peritoneum with no adhesions' even after so severe a peritonitis. 4. Unusually late, overwhelming, but short toxic erythema with sud- den onset and equally sudden recovery. The Treatment of Chronic Gastritis. — George M. Niles (Charlotte Medical Journal, August, 1920) divides the treatment into prophylactic, hygienic, local, dietetic, medicinal, and mineral water. Under the head of prophylactic treatment, all contributing or aggravating causes should be corrected. Deliberate eating, adequate mastication, and thorough insalivation should be insisted upon, also the treatment of pyorrhea, if it is present. It is well to rest both before and after meals. Locally, excessive mucus should be removed and the gastric mucosa soothed. Hot water and alkaline medicines help. Lavage is indicated in the presence of exces- sive mucus, which envelops the food and prevents its saturation by the gastric juices. Lavage should not be performed oftener than once a day, and the stomach should be free of food. It is well to use plain water at first ; later, potassium permanganate, one grain to the pint ; sodium bicarbonate, sodium chloride, silver nitrate (five grains to the pint; cal- cined magnesia, or boric acid. Where marked atony is present electricity should be employed. A diet rich in carbohydrate with a minimum of proteid is desirable. For hyperacidity, alkalies should be used ; in subacidity or achylia, dilute hydrochloric acid, six to ten drops, may be given after meals. This can be administered either alone or in com- bination with pepsin or nux vomica. Before meals quassia, condurango or cinchona may be given. Mineral waters are used to stimulate secretion. Multiple Resections of the Small Intestine. — Ernest L. Hunt (Boston Medical and Surgical Journal, September 2, 1920) says that in cases of severe traumatism to the intestine multiple resec- tions are possible and to be utilized where a single resection would deprive the patient of an undue amount of bowel. In such cases, where the para- lytic ileus has begun or its supervention is to be clearly anticipated, primary enterostomy ])roximal to the traumatized area is theoretically indicated. In cases of postoperative ileus enterostomy should not be too long deferred. Its proved value entitles the patient to its benefits without waste of time on less efficient measures. Interperitoneal Adhesions. — R. J. Behan (American Journal of the Medical Sciences. Sep- tember, 1920) discusses the results of his experi- mental investigations concerning interperitoneal ad- hesions, and advocates the application of a five per cent, mixture of boric acid with lanolin to the peri- toneal surfaces, which he has found to give much relief from pain and to tend to prevent adhesions, although it does not do the latter with certainty. The lanolin must be as pure as possible. Most of that on the market is contaminated in various ways. It should also be sterilized three times on three different days, each time for half an hour at a temperature of over 212°. Before being used it should be heated so that it is absolutely fluid, and should be applied very hot to the peritoneal surface. The bowel should be dry before its application. It does not act in the presence of inflammation. Treatment of Cancer of the Rectum. — Charles J. Drueck (American Journal of Surgery, August, 1920) in giving the treatment of cancer of the rectum formulates the following in regard to the technic of the operation which must be strictly adhered to if satisfactory results are to be obtained : 1. That an abdominal anus is necessary. 2. That the whole pelvic colon, with the exception of the part from which the colostomy is made, must be removed because its blood supply is contained in the zone of upward spread. 3. That the whole of the pelvic mesocolon below the point where it crosses the common iliac artery, together with a strip of peritoneum at least an inch wide on either side of it, must be cleared away. 4. That the group of lymph nodes situated over the bifurcation of the common iliac artery are in all instances to be re- moved. 5. That the peritoneal portion of the operation should be carried out as widely as possible so that the lateral and downward zones of spread may be effectively extirpated. 40 PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. [New York Medical JournalI The Mental Factor in the Chronic Intestinal Invalid. — John Bryant (Boston Medical and Sur- gical Journal, February 26, 1920) reports two cases which illustrate two distinct types of mental com- motion which are often encountered in the treat- ment of the chronic intestinal invalid. In one the mental commotion was due to a summation of general causes ; in the other it was due to two spe- cific factors ; in both the relief of the mental com- motion proved to be a very important factor in the recovery of the patient. Early Radioscopic Signs of Pyloric Stenosis. — De Keating-Hart {Prcsse medicalc, April 10, 1920) describes two signs which have already enabled him in a number of instances to detect pyloric stenosis before clinical or x ray findings had revealed its presence. The first sign is a particular change of shape in the gastric shadow whereby the latter assumes the appearance of a German pipe. The other sign is an interrupted, rhythmical displace- ment of the upper surface of the fluid contained in the stomach. This displacement is synchronous with the respiratory movements but is of greater amplitude, indicating a pronounced effort on tht part of the organ to empty itself. The first of these manifestations is only a probable sign of pyloric stenosis, but the second is a certain sign of it. The Tongue : Its Indication for Treatment of Disease. — M; W. Thewlis (Medical Reviezv of Reviews, June, 1920) says that a study of the tongue will give many valuable suggestions for treatment of disease ; it is often disregarded, espe- cially by young practitioners. A red, clean tongue is an indication for an acid mixture; red tongue with prominent papilliE is an indication for the use of small doses of arsenic. Acids will relieve an acid stomach and alkalies will relieve an alkaline condition. Coated tongue is an indication, for mercury and a saHne laxative; if stools are light in color, mercury is indicated ; if dark, podophyllin is needed. A moist tongue which becomes dry under alcoholic stimulation denotes that the latter is doing harm. The tongue is often dry in the aged. Acute Infectious Enteritis with a Polyneuritic Syndrome. — Frederic J. Farnell and Arthur H Harrington (American Journal of the Medical Sc ienccs, July, 1920) r-^port fifteen cases of this nature. To sum up this report, it would appear that there was introduced into the body an exogen- ous toxin (staphylococcus infection) ; that it was introduced into the gastrointestinal system and there produced an acute infective gastroenteritis ; that there was a transmission of the infective agent from the intestinal tract to the general circulation, producing a septicemia, staphylococcus in type ; that for reasons not yet explained this particular infection had a selective action upon the peripheral nervous system and caused the symptom-complex known as peripheral polyneuritis ; clinicopathologic- ally the milk, throat cultures, tlood, fecal examina- tions, and urinary tests for bacteria showed in gen- eral the staphylococcus; pathologically there was observed an acute hemorrhagic gastroenteritis, mul- tiple focal necroses of infectious origin in the liver, and acute hemorrhagic neuritis with hemorrhages between the nerve bundles. . Botulism from Canned Ripe Olives. — Herbert W. Emerson and George W. Collins (Journal of Laboratory and Clinical Medicine, June, 1920) state that five small outbreaks of botulism have occurred in the last six months, caused by eating ripe olives packed in glass containers. Four of the outbreaks were due to Bacillus botulinus of the Boise type, or Type A. Antitoxin for one type is specific for that type alone. As a preventive meas- ure against the occurrence of further outbreaks of botulism, the authors recommend the advisability of government supervision over the plants, which supervision should also include the packing and canning plants. The Saliva in Diabetics. — F. Rathery and L. Binet (^Prcsse medicalc, May 1, 1920) state that the saliva of diabetics presents certain special features,, being scanty, often viscid, rather frequently acid in reaction, and in some instances containing notable amounts of glucose. They were able to show ex- perimentally that in anirhals in which the blood sugar has been increased either by intravenous in- jection of glucose or by complete pancreatectomy elimination of sugar through the salivary glands takes place. There occurs clinically a condition that may be termed glycosialorrhea. This condition may accompany glycosuria, alternate with it, or occur independently without the appearance of any sugar in the urine. Experiments on the Utilization of the Calcium of Carrots by Man. — Mary Swartz Rose (Journal of Biological Chemistry, March, 1920) carried out feeding experiments on four healthy young women to determine the utilization of the calcium of car- rots. In all cases the calcium intake was near the estimated minimum for equilibrium. Three of the subjects showed a positive calcium balance, and in the fourth case the loss was. small. When the carrots supplied about fifty-five per cent, of the .cal- cium one of the subjects had about the same reten- tion as when she was on a diet in which seventy per cent, of the calcium was derived from milk. Thus it is apparently possible to meet the requirement of the adult human for calcium largely, if not wholly, from carrots. Antiscorbutic Properties of Raw Beef. — R. Ad- ams Butcher, Edith M. Pierson. and Alice Blester (Journal of Biological Chemistry, 1920) fed guinea- pigs on a diet of oats, water, and an amount of milk sufficient to improve the diet but insufficient to prevent scurvy (twenty-five c. c. of autoclaved milk, or twenty c. c. of pasteurized milk). Scurvy developed and the animals died. To. this diet were added water extracts of raw lean beef, representing five, ten, fifteen, and twenty gm. of raw beef. How- ever, this had no effect on the time of onset of scurvy or in the length of life of the experimental animals. On the addition of orange juice to the basal diet scurvy was prevented, both in the presence or absence of meat extract. The conclusion is drawn that the excellent condition of the animals on the orange juice and beef extract diet shows conclusively that the poor condition of the animals on the beef extract diet was due to the absence of the antiscorbutic vitamine rather than to any dele- terious properties of the beef. January I, 1921.] PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. 41 Observations upon Various Types of Diabetics under the Present Method of Treatment. — F. Gorhani Brigham (Boston Medical and Surgical Journal, August 5, 1920) presents the following con- clusions based on a study of a large number of diabetics over a period of ten years: 1. That by all the modern methods of low calory diet the diabetic patients do better than by former methods. 2. That without careful blood estimations diabetics cannot be satisfactorily treated and good results obtained. 3. That the complications of diabetes will develop even though the urine contains no stigar if the blood figures remain high. 4. That the prevention of obesity will reduce the number of diabetics tremen- dously. 5. That the stud/ of other functions, such as the kidney function, and the removal of all possible foci of infection, are essential to having the diabetic patient do well. 6. That rRutine twenty- four hour urines must be more frequently done, or routinely done, to be able to recognize diabetes as well as other kidney conditions early, and allow earlier treatment. 7. That the disease diabetes illus- trates the importance of laboratories where simple routine analyses can be done at a reasonable figure. The Islands of Langerhans in Diabetes. — Moses Baron (Surc/crv, Gynecology, and Obstet- rics, November, 1920) concludes that: 1. Pancreatic lithiasis is a rare disease, which occurs mostly in males during the fourth decade. 2. The obstruction of the pancreatic duct leads to an advanced atrophy of the pancreas accompanied more or less by fibrosis. The islets may remain intact even when the acini disappear completely. 3. The islets as epithelial structtires which are entirely independent of the acini and have no rela- tion to or communication with the dticts. 4. Changes in the islets — such as degeneration, necrosis and fibrosis — generally occur late in the disease, probably as a result of a superimposed secondary infection, consequent to a prolonged stasis in the ducts. 5. In complete accord with the results obtained experimentally in animals, occlusion of the ducts by calculi in man does not result in diabetes mellitus unless there be actual injury to the islets. 6. Cases of pancreatic lithiasis presenting symp- toms of hyperglycemia and glycosuria reveal definite lesions of the islets at atitopsy. 7. The sttidy made bears out the conclusions that the islets secrete a hormone directly into the lymph or blood streams (internal secretion), which has a controlling power over carbohydrate metabolism. 8. Attempts at regeneration of injured pancreatic tissue manifest themselves in a definite hyperplasia of the ducts. 9. The principal clinical findings in cases of pancreatic lithiasis are coliclike epigastric pains often associated with temporary glycosuria, steator- rhea, alimentary glycosuria, incomplete digestion of meat fibres as revealed by the persistence of the nuclei in muscle fibres in the feces, and, occasionally, the presence of whitish or grayish pancreatic stones in the feces ; the late stages are often accompanied by diabetes mellitus. 10. Operations on the pancreatic duct are often successful. The danger of fat necrosis as a result of the escai)e of fluid appears to be negligible. 11. The histopathology of the islets in diabetes falls into three main types, wJiich are, in the order of their importance, as follows : fibrosis, hyaline degeneration, and arteriosclerotic changes. The pathogenesis of these lesions may not be very dis- similar to that of nephritis when taken in the broad sense. The differences in the intensity of the pathological changes in the kidney as compared with those in the pancreas may be explained by the marked dififerences in the characters of the two organs. In the kidneys, any glomerulitis or other changes in the glomeruli are followed or accom- panied by alterations in the tubules ; no such changes affect the tubules or acini in the pancreas, since the' islets are entirely distinct from the latter structures. Blood and Urine in Pancreatic Disease. — -Cam- midge and others (Lancet, August 21, 1920) estab- lish a relationship between the amount of dextrin in urine and blood (which they name the difference valtie), and the state of the pancreas. The authors describe a method for measuring this difference value. They find, 1, that the proportion of dextrin in the blood varies directly with that in the urine ; 2, that the proportion of amylolytic ferment in the blood and urine varies inversely as the difference value and directly as the percentage of sugar present, and, 3, that both are dependent on the sugar present. Control experiments on depancre- ated animals indicate that an increase in the dif- ference value of the blood is a prediabetic condition. 1. When the gland is partly or wholly removed or functionally impaired, the sugar content and the difference value of the blood and urine rise. 2. The substance on which the difference value depends is derived from the glycogen of the liver. 3. An amylolytic ferment which acts on the glyco- gen is released from the liver into the blood or urine. 4. In the normal state the pancreatic secretions and the ferment of the liver maintain a balance which is disturbed in disease, resulting in abnormal conditions. 5. When pancreatic activity is decreased the dex- trin content first and then the sugar content is increased and a prediabetic condition occurs, fol- lowed by hyperglycemia and glycosuria. A Case of Paget's Disease Following a Trauma. — Dr. Stefano Gatti (Arcliivio generate di ncuro- logia e psichiatria, March, 1920) describes in full the history and clinical symptoms of a case of Paget's disease in which radiology confirms his diagnosis and helps to exclude other diagnostic possibilities. It also shows very clearly the structural peculiarities of the osteitic process, in this case downward toward the knee joint and upward as far as the sacroiliac articulation. The patient's ascendents had shown in their history tuberculosis and scrofula on the father's side, general paresis in the mother, with cardiovascular difficulties on both sides. The patient showed no syphilitic signs. It is believed that the trauma he sustained, a fall upon the ice, acted through a lesion of the sympathetic upon a constitu- tion predisposed to trophic alterations of a pluri- glandular nature. To the general hormonic dis- equilibrium the trauma added dynamic vasomotor factors causing a special perversion of the dystrophy manifested especially in the osteitis. Proceedings of National and Local Societies AMERICAN PEDIATRIC SOCIETY. Thirtv-second Annual Meeting, Held in Highland 'Park, III., May 31, June 1 and 2, 1920. The President, Dr. Thomas S. Southworth, of New York, in the Chair. ( Continued from page 1052, Vol. cxii.) Paralysis of the Respiratory Muscles. — Dr. W. McKiM Marriott, of St. Louis, said the chief interest in this case was in the treatment applied. The patient was a girl ten years of age who had sut¥ered from a severe attack of diphtheria six weeks previously. Paralysis developed of the palate, ocular muscles, legs, back and neck muscles, and partial paralysis of the arms. Ultimately the diaphragm became involved, so that it failed to move at all during inspiration. The thoracic respirations were at first very active, later the inter- costal muscles began to lose their power and the child became cyanotic and semicomatose. The child was obviously dying from suffocation, and it was thought that if the respirations could be maintained for a sufBcient period of time to allow for restora- tion of function of the respiratory muscles that recovery would be possible. Artificial respiration was given by means of the Erlanger-Gessel air cur- rent , interrupter connected with a nitrous oxide mask. The child failed to cooperate at first, but later it was possible to get her to open the glottis at the right time so that air could be forced into the lungs at the regular rate. The effect was immediate. The cyanosis was relieved and after a period of about ten minutes of artificial respiration the child fell asleep and the mask was removed. Cyanosis slowly developed and was again reUeved by a period of artificial respiration. This was kept up more or less continuously for five days, at the end of which time the function of the respiratory muscles began to return and the child was able to breathe without the aid of the apparatus. She made a complete recovery and is now in perfectly good health. A Case of Cardiospasm. — Dr. Godfrey R. PiSEK, of New York, said that the occurrence of cardiospasm in early liie was still so rare as to make it justifiable to report this case. Since adult cases might trace their inception to early life or to congenital defects, the pediatrist might well con- sider these cases worthy of study. Neurotic or primary cardiospasm was attributed by some author- ities to a contraction of the left crura of the dia- phragm, by others to defective innervation, or to localized atony of the esophagus. The case reported was that of a girl, twelve years of age, who first came under observation in Sep- tember, 1919. The family and past history were negative. When three or four years old the child exhibited a strong will and was said to be "tem- peramental." This trait grew stronger as she grew older ; otherwise she was an outdoor athletic child. She had a peculiar appetite, disliking vegetables, eggs, and sweets. About a month before coming under observation she complained that food choked her and at night she had a similar difficulty, com- plaining of a strangling sensation. A cough de- veloped in connection with the night spasms, un- conscious as far as the patient was concerned, and upon which codeine had no effect. Physical ex- amination revealed nothing abnormal except some retraction of the supraclavicular and infraclavicular spaces, a slight tremor of the upper eyelids, a ten- dency to relaxation of the spine and bowing of the shoulders, and evidence of orthostatic albumi- nuria. Radiographic and fluoroscopic examination confirmed the diagnosis of cardiospasm. After an esophagoscopy under general anesthesia a moderate dilatation was done, but no anatomical basis was demonstrable. • Bougies were passed at about fort- nightly intervals until her departure for Florida in March of this year. In the South she did well at first, but she contracted malaria, lost weight, going down rapidly to eighty pounds, twenty pounds below normal, and the original symptoms of her cardio- spasm returned. She was brought North and care- fully examined again. The gastric contents showed retention, and the fluoroscopic examination a con- siderable dilatation of the esophagus with a smooth fusiform constriction at the cardiac end. Bougies were passed every fourth day. She was given atropine and a measured diet of 3,000 to 3,500 calories a day, and she gained fifteen pounds in twenty-nine days. Whether it would be necessary to pass a duodenal tube and give the stomach a complete rest for a time was still a question. This case showed that it was not so easy to treat this condition as one was led to suppose by the literature. Congenital Atresia of the Esophagus. — Dr Henry L. K. Shaw, of Albany, said he reported this case for the purpose of emphasizing the historical side more than the clinical. The child gave a his- tory of food coming out of its nose, and on attempt- ing to pass the stomach tube it went down only a short distance. After giving barium the x ray showed the esophagus filling, but the barium did not pass through to the stomach. Examination of the lungs showed them filled with fine rales. The child died and at autopsy it was found that the upper third of the esophagus ended in a cul-de-sac and had no relation to the 4ower part which opened into the trachea. A similar case was reported in 1682 and another in 1703 by a Dr. Gibson, physician general to the British Army and a grandson of Oliver Crom- well. Dr. Shaw read this description, which was so accurate that it would be difficult to improve, upon it today. Primary Sarcoma of the Thymus. — Dr. L. Emmett Holt, of New York, said this patient was a child, six months old, with symptoms dating back only four weeks. The parents were healthy, as were two other children. This child was small and gained in weight slowly, weighing nine and a half pounds at the age of six months. The symptoms were merely an increasing pallor and slight fever. There were minute hemorrhages over the neck and extremities. The case was looked upon as one of severe secondary anemia of unknown origin. The January 1. 1921.] PROCEEDINGS OP NATIONAL AND LOCAL SOCIETIES. 43 temperature ranged between normal and 103° F. As the hemorrhages continued to appear, a trans- fusion of blood was given, but was of no perma- nent benefit. The child failed rapidly and died. At autopsy a thymus weighing thirty-six grams was found, which was very large, the upper limit of the normal being ten grams. Beside the sarcomatous condition of the thymus similar changes were found in one of the lymph nodes, in the spleen, and in the lungs. The case was interesting because the child presented none of the symptoms usually asso- ciated with enlarged thymus, and because of the rarity of sarcoma of the thymus in infants and young children the case was perhaps unique. Heart Displacement Apparently Due to Medi- astinal Emphysema Following Aspiration Pneu- monia. — Dr. E. C. Fleischxer stated that this pa- tient, a boy, three and a half years of age, following a fall into a sand pile, became wheezy. Four hours later he was brought to the hospital with sibilant rales over the lungs, both anteriorly and posteriorly. The X ray showed no foreign body and no condi- tion calling for surgical intervention. The heart was displaced slightly to the right. The boy con- tracted a definite pneumonia on the left side, in- volving the middle lobe. The displacement of the heart did not seem to be due to fluid. At the end of forty-eight hours a subcutaneous emphysema appeared above the clavicle and extended down to the pelvic bone. The pneumonia subsided, to be followed by a bronchiectasis in the left lung. He had a prolonged illness, but the x ray taken five months after the accident was to all intents and purposes normal. In this case the heart had gone rapidly and completely to the right. It seemed reasonable to believe that injury during the accident had caused air to push through the lung and force the heart to the right, and then work its way out into the subcutaneous tissues. A Case of Lymphosarcoma. — Dr. Charles A. Fife, of Philadelphia, said the unusual features which prompted him to report this case of lympho- sarcoma were: 1. The treatment by x ray of an en- larged cervical lymph node, the probable primary lesion, on the supposition that it was tuberculous. The node had not been excised. There was no other evidence of tuberculosis. 2. Wide metastasis, within five months of the cessation of rontgenism. 3. The extensive involvement of the tracheobron- chial lymph nodes producing massive exudation into the left pleura, but causing no other signs of medi- astinal compression. 4. The high, irregular tem- perature, extending over a period of one year. 5. The polynuclear leucocytosis in blood and lym- phocytosis in pleural exudates. 6. The tremendous enlargement of the spleen and of the liver. 7. The varieties of previous diagnoses, including influenza, endocarditis, secondary anemia, tuberculosis, adeni- tis, leucemia, Hodgkin's disease, and substernal empyema. 8. The rapid reduction in size of the bronchotracheal lymph nodes, and the improvement in the condition of the patient after x ray treatment to the mediastinal region. 9. The marked el¥ect of x ray and radium on the lymphosarcomatous tissue as shown in the pathological specimens. The patient was a boy, nine years old, giving a negative medical history until his seventh year, when a slowly enlarging right cervical lymph node was detected. Notwithstanding the removal of tonsils and adenoids the gland attained in ten months the size of a large egg. After three rontgen treatments given in the course of a month the mass became the size of a hickory nut, and after twenty treat- ments, in fifteen months, the disease was thought to be eradicated. The Doy returned about four months later with a recurrence and died six months after coming under observation. The hemoglobin had fallen to thirteen per cent., the red cells to 500,000, and the whites to 2,000, eighty per cent, being lymphocytes. The postmortem diagnosis was small and large celled lymphosarcoma. The struc- tures involved were the cervical, tracheobronchial, and retroperitoneal lymph nodes, the spleen and the liver. The chief histological interest lay in the fact that the nodes low down in the abdomen where they were unaffected by radiation were full of typical, active tumor cells, while the lymph nodes in rogions treated by x ray or radium showed retro- grade changes in the tumor cells, and thus many tumor cells were replaced by dense connective tissue. The Duct Sign in Mumps. — Dr. David Mur- ray CowiE, of Ann Arbor, reported that in ninety- seven per cent, of fifty-seven cases of parotid mumps a red spot was observed at the orifice of the Steno's duct which developed and disappeared under the inflvience of the disease. The duct itself became teatulated. The detailed description of the color change and the duct involvement was given, and illustrative cases cited. The sign developed early in the disease, sometimes ahead of the swell- ing of the parotid, and disappeared when the duct returned to normal. The sign was uninfluenced by the degree of fever. Submaxillary ducts showed no redness when the submaxillary glands were involved. Whether the duct sign was pathognomonic of specific parotiditis, or was present in other acute inflammatory conditions, had not been determined. Because of the occasional occurrence of teatulation of Steno's duct in a certain percentage of apparently normal persons and tlie ocasional finding of red- ness of its orifice, careful differentiation should be made. The duct sign ^liould be regarded simply as corroborative evidence of parotid gland involve- ment. A Case of Priapism Resulting from Rapidly Spreading Malignant Myxosarcoma with Gener- alized Metastasis. — ^D'r. David Murray Cowie re- ported this case, the unusual feature of it being the early age of the boy, nine years. Streptococcic Angina with Purpura Hemor- rhagica and Multiple Infarcts of the Skin and Subcutaneous Tissue. — Dr. Walter R. Ramsey, of St. Paul, stated that this patient, two and a half years old, was. brought to the city from a distance of two hundred miles. His family and past history were negative. His present illness began with a sore throat two weeks before. After a few days there was swelling of both legs and an offensive odor from mouth and nose. Upon arrival at the office the child was in a moribund condition. The skin and mucous membranes were extremely pale and there was marked edema about the face. 44 PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES. [New York Medical Journal. the eyes being swollen shut. The legs and feet were markedly edematous. There were numerous petechial areas scattered over the entire body. The fauces and tonsils were covered with a foul gray membrane, and the entire mucous membranes of the mouth, including those of the lips, were gan- grenous. The temperature was 104° and the pulse was rapid and weak. The condition was so sus- picious of diphtheria that 20,000 units of antitoxin were given immediately. The culture, however, proved negative. The purpura cleared up under this treatment. Deep sloughs developed in a few days on the right wrist, on both ears, both elbows, and on the perineum. The palate sloughed ofif. The middle phalanx of the middle finger on the right hand sloughed out, and later healed perfectly, leaving a finger with one phalanx missing. A dark area over the occipital region sloughed out and part of the bone also. All these areas healed under Dakin's solution, applied four times a day. Anaphylaxis Following an Intradermal Protein Sensitization Test. — Dr. Henr\ J. Gersten- BERGER and Dr. J. H. Davis, of Cleveland, reported this case, which showed the following points of interest: 1. A boy, seventeen months old, who had never received egg in any form, presented an ex- treme anaphylactic shock after an intracutaneous administration of egg yolk allergen and egg albumin in doses of one and two mg. 2. This child, who had received cow's milk from his third week of life and who had suffered from eczema and asthma, showed a negative intracutaneous test to cows' milk casein and cows' milk albumin. The intracutaneous injection of cows' milk allergen responded within twenty-four hours with an indurated and red area of infiltration not unlike that of an ordinary positive Von Pirquet test, but entirely dififerent from an urticarial wheal. 3. This same boy was not sensi- tive to other proteins. 4. The first severe anaphy- lactic shock on December 8th did not prevent the development on December 13th of a second, follow- ing the administration of egg yolk allergen five days later. 5. The x ray photographs made at dififerent intervals on the same day showed a definite wide abnormal thymic shadow and again a perfectly nor- mal picture. The former, as found by fluoroscopic examination, occurred during extreme expiration, the latter during extreme inspiration. 6. The thy- mus gland, if it really were large in an abnormal sense, did not produce the respiratory difficulty in a mechanical way. 7. This patient might be a case of status lymphaticus and this condition might be responsible for his congenital pathological sensitive- ness to egg proteins and his anaphylactic reaction. If, however, he should be found not to be sensitive to other proteins, especially horse serum and horse hair protein, the status lymphaticus could hardly be accepted as a causative factor in his condition, for it would be difficult to imagine how a status lymphati- cus could make a child sensitive solely to egg pro- tein and not to oats, milk, horse serum or horsehair proteins. The child was revived from his severe anaphylactic shock by means of subcutaneous injec- tions of adrenalin and the use of artificial respira- tion. One should always have adrenalin at hand while making these tests. Has Malt Soup Extract an Antiscorbutic Value? — Dr. Henry J. Gerstexberger, of Cleve- land, reported that while studying the respiratory quotient of scorbutic infants, it was decided for definite reasons to feed these infants with Keller's malt soup, a mixture which had made for itself a record of producing and never curing scurvy. During this study three infants with marked and severe scurvy recovered unexpectedly in a rapid and complete manner. Dr. Gerstenberger discussed the factors that might have influenced the antiscor- butic content of this special lot of malt soup extract. A Brief Report on Lactic Acid Milk. — Dr. DeWitt H. Sherman, of Buffalo, gave a report on some original work that he and his associate. Dr. Harry R. Lohnes, had been doing this last winter on lactic acid milks. As a therapeutic food of many years' standing'the various accepted reasons for its beneficial effect were discussed. At first the good results were supposedly due to the Bulgarian bacillus. This idea had iDeen stated to be incorrect. The second reason was that the increased acidity of the gastric contents, as they passed into the duo- denum, stimulated the intestinal secretions. This had been put aside. The third reason, which at present seemed most rational, was that lactic acid was effi- cient through Meltzer's law of contrary innervation ; that it was productive of good results through the increased amplification of the peristaltic wave, and by this increased motility, function was increased. He compared the relative value of protein milk with lactic acid milk and showed some of their dififerences. He questioned the extolled value of protein milk because its soluble salts were removed and its insoluble salts, those of calcium and mag- nesium, were in excess. He appreciated the value of protein milk in those infants whose tolerance for sugars was broken. He laid stress on the acidity of the lactic acid milk as a reason for the infants refusing it or rejecting it. The desired acidity he placed at seventy to ninety, as measured by a deci- normal sodium hydrate solution. To keep this acidity he gave two original methods for making lactic acid milk. The first was to culture the boiled and hence sterile milk, and put it away at a temperature of 85° F., in an ordinary icebox so commonly found in the household. It was to remain there over- night, and in the morning would be found of approximately the correct acidity. It was then to be boiled again to destroy the activity of the Bulgarian bacillus, and put away on the ice. The second method was even simpler. Culture the boiled milk, allow it to stand in a warm place, and in twenty-four hours the acidity would reach 180 to 190, possibly 200, an acid reaction of sufficient degree to destroy the Bulgarian bacillus. Dilute this very acid lactic acid milk with an equal amount of sweet milk, and the correct acidity is secured. Upon adding the two a fine clotting occurs, and when boiling the second time active stirring is essential to retain a homogeneous mixture. To make the formulae flexible in reference to fat, a skimmed lactic acid milk was first used, and as indications permitted, whole lactic acid milk was gradually substituted for it. (To be continued.) New York Medical Journal INCORPORATING THE Philadelphia Medical Journal Medical News A Weekly Review of Medicine, Established 18^3. Vol. CXIII, No. 2. NEW YORK, SATURDAY. JANUARY S, 1921. Whole No. 2107. Original Communications THE FAMILIAL DISTRIBUTION OF THE MIGR.'MNE-EPILEPSY SYNDROME.* By J. Arthur Buchanan, M. D., Rochester, Minn., Fellow in Medicine, The Mayo Foundation. Numerous studies have been made in the attempt to prove the origin of the tendencies which lead in certain perspns to essential epilepsy- Various sub- stances have been incriminated, but as time passed all have had to be more or less definitely excluded. The impetus to the study of the germ plasm, brought about by the publication of Weismann's monograph on this basic plasm in the interrelations between generations, has stimulated the study of its role in the transmission of epilepsy. If epilepsy is her- editary the factor which is the determiner of its subsequent manifestation must be contained in either the spermatozoa or in the ovum, and there- fore, as Hippocrates said, epilepsy begins to be formed while the fetus is iii utero. Mendel preceded all investigators in showing the germ plasm to possess the ability of distributing .determiners of transmissible characters in certain more or less fixed ratios (3). This lead has been followed by general biologists ; hundreds of charac- ters have been worked out definitely so that a breeder can know within very narrow limits what the physical make up of the next generation will be. Until the present time this subject in the human race has received very little consideration, and prob- ably only in the hemophilic have we evidence that a peculiarity of the human race is definitely segre- gated during the manifold changes that take place in the development of the fertilized ovum. Shortly after beginning my work in the Mayo Foundation I was struck with the occurrence of a rather fixed numerical ratio between the normal and the abnormal in families subject to migraine. Also when I carefully took the histories of essential epileptics for information concerning the immediate parentage, the siblings of the patient, and, when possible, concerning the grandparents, I obtained cL history of transmitted migraine in a good majority of cases. Our endeavors to collect data about sus- pected hereditary conditions are not more successful because of the belief that if the father and mother are clear of any manifestations of the condition there is nothing to be gained by carrying investiga- tions into the side lines. This is a gross error, *Presented for publication November 30, 1920. and one which has prevented the collection of more ample and accurate data. The father and mother may be free of the condition although they have the ability to transmit the condition ; they are spoken of as the heterozygotes, and it is the study of the heterozygotes that necessitates the keenest scrutiny. The study of the homozygote, the person with the condition, who is pure in the mendelian sense, and of the homozygote's family reveals convincing in- formation. In the investigation of the heterozygote inquiry should be made concerning brothers and sisters, brothers and sisters of the immediate pa- rents, and the grandparents. Definite notation must be made of the number of persons in each generation so as to ascertain numerically those who have and those who do not have the condition. The conception of epilepsy as an expression of the mendelian segregation of the germ plasm leads to the thought that if such be the case, convulsive seizures at various times are physiological for the patient. The seizure represents the end of yet un- determined cyclic biological processes in the gen- eral economy of the subject. The term hereditary disease for epilepsy, migraine, or any other condi- tion is not correct in the true sense of the word disease. The appearance of a true hereditary con- dition in man leads to the necessity for the classifi- cation of a subvariety of mankind and this sub- variety calls for a different physiological interpre- tation than that applied to mankind as a whole. It is apparent from the findings quoted in this paper that in the migraine-epilepsy syndrome we have evidences that there is a subvariety of man charac- terized by painful or convulsive seizures which must be chemical in their substrata. It is impos- sible to conceive of the determiner of an hereditary character as anything else than a chemical substance, since everything that results from the activities of the germ plasm is chemical in nature. Given an unknown chemical substance in the germ plasm, a product must result that is entirely or to a large extent dififerent in its physiological chemistry. The proof that the epileptic is the possessor of a physiological chemistry that is dififerent from that which we call normal for man is being demonstrated with difficulty hut gradually by numerous workers. Binswanger has called attention to certain sero- reactions in the epileptic which have a certain de- gree of variability with the progress of the condi- dition. Thabius and Barbe have found the spinal fluid of epileptics to contain extractives below nor- Copyright, 1921, by A. R. Elliott Publishing Company. 46 BUCHANAN: MIGRAINE-EPILEPSY SYNDROME. [New York Medical Journal. mal : increased ash and chloride content, and de- creased albumin content. Allers has found the chemistry of the postconvulsive albuminuria asso- ciated with an unknown acid production. Tinte- mann found that the total acidity of the urine is in- creased, and the increase is due' especially to phos- phoric and uric acids. The chemical instability of the bodily mechanism of the epileptic has been demonstrated by Florence and Clement, who were able to produce convulsions in the epileptic by the administration of ammonium acetate or carbonate, unless the patient was under bromide medication. These two investigators also found that the essen- tial epileptic oxidizes benzene more rapidly between attacks than the normal person (during the attacks the oxidation is less rapid), and that phenol sul- phates appear in the urine sooner in the epileptic. Handelsman has proved, in spite of many asser- tions to the contrary, that cholin has nothing to do with the production of convulsions in the essential epileptic. Loewe in the study of urine from epilep- tics found a variable amount of undialyzable sub- stances. Allers and Sacristan failed to find a nitro- gen equilibrium in epileptics, which they were un- able to explain. They are also investigating the purin metabolism. Trevisanello has found a marked anaphylactic reaction in guineapigs treated with the blood serum and spinal fluid of the essential epileptic, while controls treated with serum and spinal fluid of normal persons did not have such a reaction. A recordable physical difiference in epileptics has been described recently by Scripture. The study of the melody plot of the voice by a special instru- ment has shown that the voice of the epileptic presents a diminution or absence of the finer fluc- tuations. This inflexibility, apart from the rigidity of monotonous speech, does not occur, according to Scripture, in any organic condition yet studied, and has been used in differential diagnostic tests with success. Clark has described in many papers the peculiari- ties of the epileptic personality. Marsh has re- cently called attention to the same condition. But one case in which this peculiar type of makeup is described is recorded in the Mayo Clinic. This patient was also the carrier of the migraine factor. I have investigated the types of personality, and I am prepared to state that this particular type rarely occurs in the patients at the Mayo Clinic. The traits of the epileptics with whom we have to deal are so excellently described in an article by Ryther and Ordway that repetition is unnecessary. It is apparent that our epileptics are in temperament, education, economic efficiency, and in personal* ex- periences identical with those found in Boston (Ryther and Ordway), but somewhat different from those found in New York (Clark). In a recent study of the nature of the transmis- sion of migraine it was found that migraine demon- strates the segregation of the determiners in the germ plasm; it presents a mendelian ratio of 3.08 to 1 (6). In a previous investigation of migraine in relation to epilepsy seventy-five per cent, of the 128 patients studied had a migraine strain in their ancestral or personal history (5). The occurrence of such a high percentage of migraine in the study of the epileptic led to the investigation of a series of epileptics in whom the family history contained a definite statement of the number of children, the presence or absence of migraine in the family, and the presence or absence of epilepsy, with a numer- ical statement of the number affected with either condition. Forty-six epileptic families were studied from the viewpoint of the distribution of epilepsy considered as a manifestation of the migraine fac- tor, and in order to learn the heritage of the children when no history of migraine had been found. The families with epileptic parentage were also studied in order to learn if they followed the same general principle. Either the father or the mother of thirty- five patients (seventy-five per cent.) had migraine, six patients (thirteen per cent.) had no knowledge of migraine or epilepsy in the family, and five (ten per cent.) fell in the heterozygote parentage group. The forty-six families studied consisted of 262 children, of whom 198 were normal, and sixty-four had epilepsy or migraine, giving a mendelian ratio of 3.09 to 1. This ratio is so nearly that obtained previously for migraine alone that they can be con- sidered identical. Forty- four (sixty-eight per cent.) of the sixty-four children had epilepsy, and twenty (31.2 per cent.) had migraine; of the latter two were the offspring of an epileptic woman mated with a normal man. Thirteen (twenty-nine per cent.) of the forty- four epileptics had migraine as an alternating, pre- ceding, or combined condition. The only patients with socalled arrested epilepsy had migraine as a replacement condition. In the study of the cross- ing of two pure strains of migraine it was found that all the children from such matings had mi- graine. One family was found in which a woman with migraine was mated with a man with epilepsy. If epilepsy is considered a manifestation of the same, basic condition as migraine, all the children in 1:his family would be expected to have either migraine or epilepsy. All had migraine ; in addition one had epilepsy, which alternated irregularly with the attacks of migraine. The series comprising this study is too small from which to draw conclusions, but it is sufficiently large to stimulate the belief that the essential con- vulsive seizures are a manifestation of the peculiar- ities transmitted to persons by the migraine factor. It also leads one to suspect that the advice com- monly given to epileptics to avoid marriage or not to have children will not eventuate in the reduction of the number of epileptics, for the basis on which epilepsy apparently depends is the person with mi- graine who is married without any thought of the type of progeny that may result. BIBLIOGRAPHY. 1. Allers, R. : Zur Theorie der postepileptischen Al- buminurie, Ztschr. f. d. ges. Neurol, u. Psychiat., 1912, Orig., viii, 361-380. 2. Allers, R., and Sacristan, J. M. : Vier Stoffwech- selversuche bei Epileptikern, Ztschr. f. d. ges. Neurol, u. Psychiat., 1913, Orig., xx., 305-326. 3. Bateson, W. : Mendel's Principles of Heredity, E.r- p crimen ts in Plant Hybridisation, Cambridge University Press, 1909, 317-361. 4. BiNSWANGER, O. : Die Abderhaldensche Seroreak- January 8, 1921.] PORTER: ANIMAL AND VEGETABLE PROTEINS. A7 tion bei Epileptikern, Miinchen. vied. IVocliciischr, 1913, Ix, 2321-2325. 5. Buchanan, J. A. : A Study of the Hereditary Fac- tors of Epilepsy, Minn. Med., 1920, iii, 526-538. 6. Idem: The Mendelianism of Migraine, Medical Record, 1920, xcviii, 807-808. 7. Clark, L. P. : The True Epileptic, New York Medi-. CAL Journal, 1918, cvii, 817-824. 8. Idem: Treatment of the Epileptic Based on a Study of the Fundamental Makeup, Journal A. M. A., 1918, Ixx, 357-362. 9. Idem: Is Essential Epilepsy a Life Reaction Dis- order? American Journal of the Medical Sciences, 1919, clviii, 703-711. 10. Idem: A Consideration of the Aftercare of Arrested Cases of Essential Epilepsy, American Journal of the Medi- cal Sciences, 1920, clx, 582-589. 11. Idem: A Psychological Interpretation of Essentia! Epilepsy, Brain, 1920, xliii, 38-49. 12. Florence, J. E., arid Clement, P. : L'epreuve de I'ammoniurie experimentale chez I'epileptique, Comp. rend. Acad. d. sc., 1909, cxlix, 462-465. 13. Idem: L'epreuve de la phenolurie provoquee chez I'epileptique, Compt. rend. Acad. d. sc., 1909, cxlix, 368-370. 14. Handelsman, J. : Experimentelle und chemische Untersuchungen iiber das Cholin und seine Bedeutung fur die Entstehung epileptischer Krampfe, Dcutsch. Ztschr. f. Nerfcnh., 1908, xxxv, 428-432. 15. Loewe, S. : Untersuchungen iiber die Harnkolloide von Epileptikern und Geisteskranken, Ztschr. f. d ges. Neurol, u. Psychiat, 1911, Orig., vii, 73-111. 16. Marsh, C. A.: A Psychological Theory of the Cause of Epilepsy, with Special Reference to an Abnormal Mus- cular Expression of a Strong Emotional Drive, American Journal of the Medical Sciences, 1920, clix, 450-458. 17. Rvther, Margherita, and Ordway, Mabel: Eco- nomic Efficiency of Epileptic Patients, Journal of Nervous and Mental Diseases, 1918, xlvii, 321-342. 18. Scripture, E. W. : The Nature of Epilepsy, Pro- ceedings Royal Society of Medicine, 1920, xiii, Section in Psychiatry, 18-23 19. Thabuis and Barbe : La Composition physico- chemique du liquide cephalo-rachidien des epileptiques. Rev. neurol.. 1913, xxi, 248-253. 20. Tintemann, W. : Die Bewertung der Befunde der Gesamt-Stickstoffausscheidung beim Epileptiker im Inter- val!, Ztschr. f. d. ges. Neurol, n. Psychiat., 1914, Orig., xxiv, 49, 52, 21. Trevisanello. C. : Untersuchungen iiber das Blut- serum und die Cerebrospinalfliissigkeit von Epileptikern, Centralbl. f. Bakteriol, 1913, Orig., Ixix, 163-166. 22. Weismann, a. : The Germ Plasm. A Theory of Heredity. New York: C. Scribner's Sons, 1912, 37-468. ANIMAL VERSUS VEGETABLE PROTEIN. By William Henry Porter, M. D., ■ New York, Professor Emeritus in Pathology and General Medicine, New York Post-Graduate Medical School and Hospital. To understand thoroughly the protein problem is no easy matter. So much so that I do not wonder at a physician who, in making a friendly criticism of my recently published book ( 1 ) , took exception to the emphasis placed upon the utility of the ani- mal as against the vegetable protein, and wrote, "I cannot follow you." This I fully understand, for the simple reason that a complete knowledge of this protein problein is the most consummate task in connection with chemicophysiology. Certain facts, however, stand out clearly, such, for instance, as these : First, at the very beginning of our life and throughout our existence in utero, the animal economy is furnished with animal pro- tein only ; Nature must have some reason for this. Second, as soon as we are expelled from the uterine cavity, the infant is given an animal protein. This particular protein, casein, is especially valuable, for it is the only known proteid, out of which all other protein substances can be produced chemically, casein having some forms of amino acids that other protein compounds do not contain, and without these amino acids nutrition cannot be maintained. As for instance, while gelatine is a protein sub- stance, it will not by itself furnish nutrition to animal life. But if a small quantity of casein is added to a large quantity of gelatine, the gelatine will become a highly nutritious protein substance, and the animal economy will thrive, as it were, on gelatine. These facts naturally stamp the animal proteins as the essential ones. Enhancing the nutritive value of* protein by the addition of a little casein unquestionably applies to many other protein sub- stances, more highly nutritious to begin with than gelatine, but less so than casein. If these facts are true during intrauterine life and early infancy, they ought certainly to be equally so as life progresses, and far more so when disease processes have to be combatted. When the term protein excess is used in connec- tion with metabolism, it indicates that more protein is entering the blood than the hemoglobin can fur- nish and distribute oxygen to reduce completely the protein substances. This refers to normal body states. For the air sacs al\Vays contain a large superabundance of oxygen, assuming the animal is breathing in anything like a natural atmosphere. When we come to deal with pathological condi- tions, the nonreduction may not be due simply to an overintake of protein, but involves many very complicated conditions, such as deficient produc- tion of hemoglobin, a too rapid blood current, a too slow blood current, toxic substances in the blood current preventing the discharge of oxygen, and interference with the power of oxygen to split the protein compounds. The two most potent fac- tors in defective oxidation, however, are a de- creased alkalinity of the blood and a diminished supply of available glucose. No matter how produced, defective oxidation means overproduction of catabolic bodies and a reduction in the amount and perfection of the nor- mal excretory products. Most notable, and the greatest index to iinperfect oxidation of the protein substances, is an overproduction of uric acid. Its determination is the easiest of all the protein cata- bolins, hence it is the most important factor. Now we come to the essential ditTerences existing between the animal and vegetable protein sub- stances as two distinct classes. The animals are monomolecular in their construction. On the other hand, the vegetable protein substances are multi- molecular in their composition. That is to say, the molecules are doubled up — how many times is not accurately known ; hence the chemist writes after the formulae n times, thus presenting at the starting point an unknown quantity. The doubling may be in the form of a 2, 4, 8, 16, 32, 74, 148, 296 mul- tiple, and so on up. This much we do know, that I 48 PORTER: ANIMAL AND VEGETABLE PROTEINS. [New York Medical Journal. they are many times multiplied, and that they must be reduced to a single molecular state before the digestive ferments can begin to peptonize them. On the other hand the animal protein substances have been reduced to the single state by our herbiv- erous friends in the animal kingdom, who have many stomachs with endless feet of intestine, as compared with the human family and other meat- eating species. The result is, that the ferment bodies in the hu- man digestive tract can immediately bring to bear their chemical digestive activity on these single animal protein molecules and convert them into a peptone. Here is where the danger lies in a too free use of the animal foods as compared with the vegetable protein substances. With the former, too much will be peptonized and the blood over- loaded with protein compounds, unless the quantity ingested is kept well within the physiological limit. When so done, however, the strain upon the digest- ive energy is kept at -the lowest ebb, while the sys- tem is being fully siipphed with constructive ma- terial of the animal protein class. On the other hand, the vegetable protein has to be split all the way down in the digestive canal, by its chemical activities, until it becomes a single mole- cule like that found in the animal kingdom before the peptonizing process can begin. In many in- stances this is a long and tedious process. So much so, that with the vegetable class from fifteen to eighty per cent, of the protein substances contained in this class is lost in its transit through the alimen- tary Canal. With the animal class the loss ranges between two and eight tenths and five per cent., thus making the animal class very much more eco- nomic from this viewpoint. This loss when the vegetable class is used exclusively is often so great that constructive nutritive activity cannot be fully maintained. The overworking of the digestive energies with a too abundant vegetable supply tends after a time to weaken the digestive energies. This, together with the over irritation by the undigested residue, and the putrefactive fermentation that is bound to follow when the digestive ferments are deficient, often becomes a menace to life. All this naturally leads to the fact that if one eats too abundantly of animal foods alone, or in conjunction with an over supply of carbohydrate and fat foods, he can and does ver)^ easily exceed the oxygenating capacity of the system. This, however, is no excuse for choosing a food supply that overtaxes the digestive energies, to cut down the protein supply. On the other hand, it shows conclusively that the correct thing to do is to keep the supply of animal foods within rational physiological limits. This is what I have always contended, because it spares digestive .and dynamic energy, and yet furnishes the system with its full ciuota of avail- able constructive nutritive material. Even though there is this wide difYerence in economic value be- tween the two classes, it does not indicate that the one class should be used to the exclusion of the other. For they both have their good and bad points, neither one having all that is perfect for the highest grade of nutritive activity. Therefore to secure the best balanced food supply, the two classes must be used, selecting from the animal class chiefly to secure the protein supply, and using the vegetables to furnish the salts and socalled vitamines. . At this point it might be well to say that with this protein problem I have been dealing only with what may be called constructive proteins ; not with the other classes, which are in the nature of acti- vating agents, enzymes, and ferment bodies, and not directly tissue builders. Neither have I tried to contrast the two classes in their many points of difference. While it might be interesting more fully to prove that the -"^ne cannot be used to the exclusion of the other, it would be too wide a digression from the main subject of this paper. This same physician in his criticism objected to the animal class on account of the large amount "of poison waste which was in process of elimination from the animal at the time it was killed, but the elimination of which was checked by his [sic] slaughter," and complained that we were compelled to take this poison waste when we obtained our protein supply from a "juicy steak." This bugaboo about poison waste and its en- trance into the system on account of its being at- tached to the animal fibre, has always seemed a pretty farfetched argument, excepting the leuco- maine and ptomaine poisons, practically developed after the death of the animal and also produced from decomposed and dead vegetable protein; both of which conditions, however, are very rarely met with. The reason that this poison waste danger is merely a scare, is proved by the fact that under normal circumstances only a fraction of one per cent, of any effete material is ever found in the blood, lymph, or tissues of the body. But their natural place is in the excreta eliminated from the animal economy and chiefly found outside the body, not within. This is a fact which does not seem to be generally recognized. In this connection it is reasonable to suppose that most animals when killed are in a fairly normal condition. Hence, very little poisonous material is taken with the carcass from the slaughter house to the retail market. Having gained the knowledge that no matter what the origin of the protein molecule is, and that it must be a single one before the digestive ferments can act upon it, the next question is, What happens to these single protein molecules? We find that they all, no matter what their origin, have to be transformed by the action of the digesting ferments into that particular form of protein known as a peptone, this being the only form in which a pro- tein substance can enter the epithelial cells lining the intestinal canal. We also know that this par- ticular protein, peptone, is a most deadly poison. We also know that in its passage through these cells it loses its identity and toxicity and emerges on the other side of the cell into the blood stream in three other forms of protein substances, namely : serum albumin, globulin, and fibrinogen, and that serum albumin is composed of three other di.stinctive pro- tein bodies. How many more there may l)e is yet to be determined. Thus, that which was a single January 8, 1921.] ROUT: PREVENTION OF VENEREAL DISEASE. 49 molecule on entering the epithelial cell lining the intestinal tract, appears in the blood in live distinct forms. Thus this protein peptone molecule becomes as distinctive as H2O does, no matter what the origin of either may have been. With this imderstanding of the digestive act, and when the digestive secretions are normally produced both as to quality, composition and amount, there is no putrefactive or abnormal fermentation taking place in the alimentary tract, and there is no toxicity of the system from this source. Thus we find that nature is quite capable of maintaining all her power to keep these horrible poisons well out of the sys- tem, and conseciuently we do not suffer from the much dreaded calamity. Let down, for any reason, the full power of the natural digestive ferments, and at once the micro- organisms of all kinds that produce pathogenic fer- mentation will get busy generating abnormal prod- ucts, some of which may have a high toxicity, which latter will poison the system, but not because an animal protein was used instead of a vegetable one. All fruits, and especially those highly charged with acids and saccharine compounds, are very prone to ferment and irritate the intestinal mucous membrane. Likewi.se all highly indigestible foods act as irritants to the mucous membrane. This irritation augments the secretion of mucus from the intestinal wall, which is often thick and tena- cious, and this mucus is in a large measure the culture medium in which the pathogenic micro- organisms thrive. Hence this class of foods should be studiously avoided if we do not wish to c"ourt real danger. Therefore my rule has been, know your chem- istry and physiology, and the composition and di- gestibility of all foods. Then select those most easily digested, least fermentable and irritating to the intestinal canal. Select from both animal and vegetable kingdoms according to the result to be obtained, and in such manner that the oxygenating capacity will not be exceeded. Then we will be following pretty close to Nature's law or laws; in fact, so nearly that we can get almost any result we desire to attain. REFERENCES. 1. Porter: Eating to Live Long. Reilly & Lee Companv, Chicago, 1920. 46 West Eighty-third Street. Further Research in the Treatment of Hyper- tension. — Leslie Thorne Thorne {Practitioner, May. 1920) says that in cases of hypertension, whether sclerotic or not, the blood pressure lis always lowered by immersion in a Nauheim bath, whether that bath is of the still or the effen'escent variety. Even an advanced condition of arterio- sclerosis does not counterindicate this treatment. The Nauheim baths are useful not only for treat- ment, but also for the purpose of differentiating between sclerotic and presclerotic hypertension, as the effect of the baths upon the blood pressure differs materially according to the condition of the vessel walls. PREVENTION OF VENEREAL DISEASE. By Ettie A. Rout (Mrs. Hornibrook), London, England. In the New York Medical Journal for October 30, 1920, Dr. Satterthwaite cjuotes me as follows (New York Medical Journal, October 9, 1920) : In fact, Miss Rout asserts that i)roi)hylaxis is success- ful when properly applied in only two thirds of the cases, as shown by. the returns of the .'\merican, Canadian, and Australian armies. What I actually said was : Wherever prophylaxis was properly applied, at least two thirds of the cases of venereal disease were eliminated. . . . In particular cases enormously better results than this were attained. The War Department, Washington (General Order No. 135, December 23, 1919), says: Its use (that is, the use of prophylaxis) appears to re duce the liability to venereal disease among those exposed to about one third of what it would be without prophylaxis Prophylaxis, or disinfection, of course does not fail at all (practically speaking) when properly applied. Failure to apply disinfectants reduces the efficacy of the system of prophylaxis. This failur^i among Paris leave men was one third due to care- lessness, one third to drunkenness, and one third to willful infection. During the latter part of the war, venereal dis- ease had to be classified as a "selfinflicted wound." Diseased women were known to charge more for sexual relationship than clean women. Such was the state of mental distraction into which some men were driven by the ordeal of Ixittle that they actually paid diseased comrades to infect them for the pur- pose of securing a temporary release from the firing line. Failure to protect the men was due at times to the entire absence of disinfectants. I know by experience that the distribution of portable dis- infectants, and the spread of a knowledge of self- disinfection, was responsbile for preventing much disease; but the critics of the socalled packet system never tell us that there was frequently no system at all and still more frequently no packets. You see, there was a war on at fhe time ! The actual fact is that the British Army succeeded in dis- tributing an average of one calomel capsule per soldier per annum. The Au.stralian and New Zealand troops on leave before 1918 were poorly provided with the means of disinfection; in 1918 not more than half the men on leave actually got their issue of disinfectants (except those going to Paris) ; after the armistice, most of our men were absent without leave at various times, and travelled very widely, so that it was impossible to provide them with disinfectants. I lectured to some 25,000 of our soldiers during May and June, 1919, and found that approximately ten })er cent, had been provided with disinfecting packets — ninety per cent, admitted going on leave' without protection. The following is a digest of a paper read by an American doctor (then in the Canadian Medical Service), viz., Captain Walker, Medical Officer in care of British Medical Report Centre, Pepiniere Barracks, Paris, before the Venereal Dis- ease Conference arranged by the American Red Cross in the Hotel Continental, Paris, in April, 1918: 50 ROUT: PREVENTION OF VENEREAL DISEASE. [New York Medical Journal. During August-Se])leml)cr, 1917 — sixty days — a little over five thousand officers and men came on leave to Paris; in 1,038 of these men venereal dis- ease developed — over twenty per cent. Leave to Paris was then closed. Leave was reopened on November 8, 1917. and at the same time there was opened the Medical Report Centre, where all British, Australian, New Zealand, South African, and Canadian soldiers on leave to Paris had to report before they could draw pay in Paris. Calomel tubes were offered, the soldiers having the option of refusal. The number who refused was approxi- mately one to the thousand. From November to March, 60,000 tubes were issued, and 29,000 prophylactic treatments given. Captain Walker stated that since his own enlist- ment he had been responsible for issuing over 100,000 tubes and giving 53,000 treatments, and that he had yet to find one man who took his tube of calomel ointment, used it as directed, and re- ported for prophylactic treatment in a properly con- ducted centre, who had nevertheless contracted venereal disease. The actual result of the preventive measures described was that from November 8, 1917, to March 31, 1918, the infection rate of over twenty per cent, was reduced to less than three per cent.— one per cent, was due to drink, one per cent, to willful infection, and one per cent, to carelessness and conceit. Speaking in regard to licensed houses. Captain Walker said that he had not found one case of venereal disease contracted in a licensed house in the city of Paris, and he could only suppose that the people who were responsible for putting the licensed houses in Paris out of bounds knew noth- ing at all about the real facts of the case. In the licensed houses of the city of Paris during the year 1917. only five cases of venereal disease were contracted, and in 1918, up to April 20th (the day he was speaking), there had not been one case of venereal disease contracted in a licensed house in the city of Paris. (Of course, the Paris houses were well conducted- and medically supervised.) Out of two hundred women arrested on the streets of Paris during the month of April, 1918, over twenty-five per cent, were found to be infected with venereal disease. But this was much better than in 1917. In the months of November and December, 1917, the French authorities had a round- up on one boulevard of seventy-one women, of whom fifty-five were infected. A few days later, about a hundred women were arrested, and ninety- one per cent, were infected with venereal disease. Nevertheless the Americans put the Paris licensed houses out of bounds to their soldiers, and the men consorted with the much more dangerous women of the streets. The British order in this respect was never enforced. I suggested the following working compromise to the English L. of C. officers and it was vmofficially accepted : 1. The British authorities in Paris do not know where the French licensed houses are ; 2. It is not their duty to find out ; 3. They have no staff for ascertaining this knowl- edge. Experienced military and medical officers knew that the licensed houses made the least dangerous provision for the nomial sexual needs of the men, and we knew that we could not extinguish or para- lyze the sexual instincts of the majority of the soldiers, however much we tried to encourage con- tinence. But we knew also that all the irregular intercourse could not be confined to the licensed houses, and therefore portable disinfectants and prophylactic stations were required ; in fact, all means of controlling venereal disease are required — social, moral, medical, and legal. Dr. Satterthwaite, on the other hand, apparently condemns medical and legal protections, although he says : We cannot, of course, abolish venereal diseases now. for the present sources of contagion must necessarily con- tinue for an indefinite time to be a danger to the public, even if no new instances of the disease should occur. More- over, we can never prevent clandestine relations. To admit this, and oppose personal disinfection, seems to me an untenable position. The answer to those who wish to rely only on moral prophylaxis, is that this method of controlling venereal infection has already broken down; that is why venereal disease has spread so widely. The answer to those who wish to rely on licensed houses only is that in Paris these did not of them- selves prevent some twenty per cent, of British and overseas troops on leave becoming infected in August-September, 1917. The answer to those who wish to rely on prophy- lactic stations only is that even in wartime these alone did not prove sufficient to control venereal diseases — the imcontrolled diseased women in Eng- land succeeded in contaminating our men faster than we could instruct the men and provide the means of disinfection. Finally, let me express my own opinion that although there are many objections — moral, social, and medical — to the licensed house system of Paris, it proved nevertheless infinitely preferable to the unlicensed house system of London. This French system, supplemented by our own issue of portable disinfectants to Anzac soldiers (Australiafis and New Zealanders), and aided most generously and most valuably by the American Red Cross Dis- pensaries and the American Army Prophylactic Stations (all of which made our soldiers welcome to their medical benefits) was responsible for the fact that Paris gave us the lowest rate of infection in 1918, whereas London gave us the highest. May I also, without offense, point out that such an inquiry as Dr. Satterthwaite asks for would be most useful in dispelling many illusions with regard to the American Army statistics? For example, in a book recently sent me for review, viz., Sanity in Sex, by William J. Fielding, published by Kegan Paul, the following excerpts are taken from a cir- cular issued by the Surgeon General of the American Army: A. During the fifty-three weeks ending September 27. 1918, there have been 178,204 venereal disease cases reported under treatment in the United States Army in France. B. Reports indicate that approximately eighty-five per cent, of this number entered the army already infected, and that approximately fifteen per cent, of all cases reported were contracted after enlistment. January 8, 1921.] BLAIR: ANTIXARCOTIC LECISLATION. 51 And Mr. Fielding says this "showed a great improvement in venereal health in comparison with men of similar ages, in civil life." He also quotes from the Social Hygiene Bulletin, September, 1919, as follows : It is usually said that of all the cases of syphilis and gonorrhea among soldiers, five sixths were contracted in civilian life and only one sixth after the men were in uni- form. A careful study of all the new cases of venereal dis- eases at five large cantonments which the Surgeon General's Office has made, shows the army in a still more favorable light. The cantonments selected were Lee, Virginia ; Dix, New Jersey ; Upton, New York ; Meade, Maryland, and Pike, Arkansas, for the year ending May 21, 1919. During this year 48,167 cases were treated. It was found that ninety- six per cent, were contracted before entering the army, and only four per cent, after. Army officials claim that these figures indicate decisively how easy it is to prevent the spread of venereal diseases when a determined effort is made to do so. I quite agree that venereal disease can be pre- vented and ought tcJ be prevented, and that the American efforts, so far as they went, were admir- able — particularly in Paris. But the American medical examiners were really not so lax and in- competent as to allow from eighty-five to ninety- four per cent, of the venereal disease cases to slide into the Army undetected. The explanation is that American soldiers were court martialled if they contracted venereal disease, and heavily fined, unless they swore that the disease was a recurrence — that they had had venereal disease before they joined the army. Naturally that is what they did swear. They could not be punished for the mechanical consequences of civil acts The figures are all right, but the facts on which the figures are based are incomplete and inaccurate. From computations based on the report of the Provost Marshal General on the first draft, it appears that there were 445,000 syphilitics and 2,225,000 men infected with gonorrhea among those registered who were not then called, says Mr. Fielding. If the American doctors de- tected all these cases, and missed some eighty-five per cent, to ninety-six per cent, of the Army cases, one cannot help wondering if there were any really uninfected young men in America ! And are we expected to believe that the Americans as civilians are the most immoral and as soldiers the least im- moral of all men? This kind of argument makes .the American Medical Service look inefficient and ridiculous, whereas actually it was the most efficient and serious among all the Allied Armies. Similarly the social services connected with the American Army were the admiration of us all — for their unfailing kindness, their broad humanity, their un- ' .\t the American Red Cross Conference in Paris, in April, 1918, Captain Walker, M. O. i/c British Medical Report Centre, Paris, said that in his opinion there were twice the number of officers concealing the disease than there were reporting it, and that to get at the actual number of infections in other ranks he firmly believed the official figures should be doubled. Speaking on July 2, 1920, Dr. J. H. Sequiera (of the London Hospital) said: .\fter the armistice it was well known that there was a large amount of concealed venereal disease in the Army. It was obvious that men would not run the risk of missing early demobilization by reporting that they were suffering from venereal disease. Colonel Harrison demonstrated this in an ingenious manner by what he calls the complication index. It was found that while there was a drop in the number of cases of primary syphilis, which can be concealed, there was a rise, in the number with secondary symptoms, which cannot be hidden. Similarly, gonorrhea, in its early stages was not reported, while the proportion of cases with epididymitis, etc., which incapacitates a man, increased in number. selfish generosity, and their thorough efficiency. But the tide of racial contamination swept on — arrested practically not at all except by disinfection ; and that tide was infinitely worse, as we now know, than can ever be revealed by military statistics.' But this standing ground for future efforts is sure: 1. Clean persons can be kept clean by disinfection. 2. Diseased persons can be prevented from .spread- ing contamination. 3. Under civilian conditions all persons desire to avoid venereal infection. Thus, in spite of the disharmony between the present social and economic conditions and the nor- mal sexual needs of men and women, racial health can be maintained; the rest is a matter of evolution. PRESENT AND CONTEMPLATED ANTI- NARCOTIC LEGISLATION.* By Thomas S. Blair, M. D., Harrisburg, Pa., Chief, Bureau of Drug Control, Pennsylvania Department of Health. In a letter recently received from Dr. Frederick R. Green, secretary of the Council on Health and Public Instruction of the American Medical Asso- ciation, I find this comment : "It is all right to dis- cuss the question of the treatment of drug addic- tion and whether or not it is an actual disease. These are purely scientific questions for discussion in technical organizations. The important thing from a social and executive viewpoint, however, is to consider practical methods for controlling the traffic in habit forming drugs. I think we are very well agreed on this and as to the methods which should be followed. I do not, of course, in any way sympathize with the ideas of some of our more extreme members that physicians should be immune from all restrictions. On the contrary, I can see no reason why the physician, as a citizen, should not be subject to the same restrictions for the public good that we are constantly urging on laymen in the form of public health measures ; but I also be- lieve that all restrictions on both physician and lay- man .should be the smallest amount necessary to accomplish the desired object. The present method seems to involve a large amount of annoyance with a minimum amount of restriction ; what we want is just the opposite. "The trouble with the Harrison law is that it is a legal evasion. It attempts to regulate traffic in habit forming drugs by means of a revenue meas- ure. It is all right to control the importation of these drugs by Federal taxation but I can see no legal obstacle to placing the distribution, after they are once admitted to this country, in the hands of the United States Public Health Service to dis- tribute through legitimate professional channels to those who have any legitimate need for them, and in such amounts for all proper uses. This, of cotirse, would be a new function for the Public Health Service to assume, yet its supervision and control of serums is very closely analogous to such work." *Read before the Philadelphia County Medical Societv, November 10. 1920. 52 BLAIR: ANTINARCOTIC LEGISLATION. [New York Medical Journal. This quotation from Dr. Green is very suggestive, and is in line with recent thought ; and the propo- sition to place the distribution of narcotic drugs in the hands of the United States Public Health Service would render necessary a government monopoly, as it were, in narcotic drugs, none but the government or its appointed agents being al- lowed to import opium and coca leaves and deriva- tives and preparations thereof. As these agents are not, in the form of the crude drugs, produced in the United States, it is perfectly feasible to invest the Federal government with this power, and it is a fact that there would not be the difficulty con- fronting the government that there is in the en- forcement of the Volstead act, which aims to con- trol the production, importation, distribution, and use of alcohol and alcoholic beverages. A governmental report (1) shows that the per capita usage in the United States, figuring all educts to an opium basis, is thirty-six grains a year for every man, woman and child in the Union, without taking into consideration smuggled in supplies. It is evident that largely unnecessary supplies are coming into the country. The 1919 report of the Bureau of Drug Control of the Pennsylvania De- partment of Health shows that the per capita com- ing into Pennsylvania through legitimate channels on an opium basis was about twenty-four grains a year. A recent survey of the public hospitals of this commonwealth, and in which all opium educts were figured to an opium basis, shows a per capita, consumption in the public hospitals of the state of only about three grains of opium a year; that is, a hospital treating one thousand patients in the year 1919 used for those patients in the course of the year three thousand grains of opium, estimating all educts to an opium basis. This same report showed that the per capita usage in the practice of the medical profession at large outside of hospitals was about fifteen grains a year, or five times the per capita usage of the hospitals. Thus it will be seen that legislation to curb the opium and other narcotic menace is necessary, but it is a difficult matter for me to speak on this subject purely from the point of view of Pennsylvania. The menace is a national one, and national legisla- tion is necessary. Furthermore, it. is necessary in any present or prospective state legislation so to shape it and its administration and enforcement as to be cooperative with the Federal efl^^orts, as the work is one work, and the Federal and state work- ers should be fully in harmony. This is imperatively necessary ; first, from the legal point of view, for as regards legislation of parallel nature for the same purpose, Federal legis- lation takes precedence over state legislation ; sec- ond, while the law is important, its administration is more important, and there are so many practical points involved in the handling of this problem that little substantial result can be obtained without the utmost of agreement between Federal and State enforcement officers. I am not at all prepared to say that the Harrison act is insufficient from the point of view of the United States Internal Revenue Bureau ; indeed, I feel that from this point of view, the Harrison law is a very good piece of legislation, but from the point of view of the physician, of the retail druggist, the dentist, the veterinarian, and the legal and other persons endeavoring to suppress drug addiction, the Harrison law is insufficient, nor can it be otherwise than such, because of the fact that the Federal power cannot, within a state, exercise the police power that the constituted authorities of the commonwealth can exercise ; hence, there is a place for state legislation to supplement the Fed- eral enactment. A serious effort has been made by the Secretary of the Treasury and the Commissioner of Internal Revenue to patch up the deficiencies of the Harri- son law by means of court and treasury decisions and internal revenue regulations. Under the cir- cumstances, a certain amount of this is necessary, but it imposes a great degree of annoyance antl bookkeeping upon professional persons handling narcotic drugs, and the propaganda of the American Medical Association, as expressed in the letter of Dr. Green, is the result of much conference with the several interests involved, and in my view, opens up a way of escape from the harshness and annoy- ance of treasury decisions and internal revenue regulations ; in other words, the distribution of nar- cotic drugs, if placed in medical hands, that is, in the control of the United States Public Health Ser- vice, would tend to render unnecessary a large part of the detailed regulations and the bookkeeping and record entries required of professional people ; therefore, from the medical point of view, legisla- tion along the lines suggested by Dr. Green is a consummation devoutly to be wished. Now, from the state point of view, permit some considerations : The Pennsylvania Ant "narcotic Act has now been tried out in practical administration ; numerous ac- tions have been brought before the courts, and no marked defects have appeared in this law, which, in the first instance, was very wisely drawn, except that the law, as now on the statute books, does not give sufficient police power to inspectors in the Bu- reau of Drug Control as regards the service of warrants of arrest and search in the case of the drug peddler and the other criminal elements vio- lating the law. These people have no stated places of business, and unless arrests are made promptly, ofttimes on sight, when violations are witnessed, the evidence is destroyed and the people disappear.- It is aimed to correct this weakness in the law at the next session of the legislature. So far as physi- cians, dentists, veterinarians and druggists are con- cerned, the law is adequate, as these people have stated places of business, maintain records, and are' easily traced, so that in the event of violation of the law they can have explanation made to them, warning served, or in the event of arrest, the jusual machinery already provided for by the law is en- tirely adequate. I do not see any occasion for a revision of the Pennsylvania Antinarcotic Act except as regards this one thing, namely, increased police power. There is, however, need for control of certain other drugs, more especially hydrated chloral, cannabis. January 8, 1921.] BLAIR: AXTIXARCOTIC LEGISLATION. 53 certain ether preparations, such as Hoffmann'^ drops, Hoffmann's anodyne, and golden tincture, and perhaps to a Hmited degree as involves some of the synthetic somnifacients. This proposed legislation should be of such character as to be satisfactory to the Pennsylvania Department of Health and to the State Board of Pharmacy, and should be enforced jointly by these two organiza- tions. The matter is now under consideration. As justification thereof, permit me to say that there is a growing addiction to hydrated chloral, promoted largely by certain proprietary medicines that should not be dispensed except on the pre- scription of a professional man. There is also a seriohs menace from ether, especially in the mining regions. The Polish miners drink ether if they can get it, and as that is not usually available, they buy Hoffmann's drops and Hoffmann's anodyne, sold throughout the mining districts in practically every grocery store and a few drug stores. They add this to coffee, becoming intoxicated from the ether and alcohol, and many accidents in the mines have occurred from such intoxication. There is also need to control cannabis for the reason that this drug is added to tobacco and is smoked, more especially in South America, but this menace is reaching the United States, and the'' smoker usually becomes insane within two years. The question of the control of synthetic somnifa- cients involves many difficulties, especially since there is legitimate sale for some of these agents in the drug stores. However, since prohibition, or alleged prohibition, has come, 'many men accustomed to alcohol are buying veronal and taking it in exces- sive doses, causing a form of intoxication and stupor that persists for forty-eight hours. A few deaths have occurred in Pennsylvania from such indulgence, and I understand that numerous deaths have also occurred in New York state. Now, as regards legislation aimed to control or to take care of the drug addict, there is a most admirable habit act on the statute books of Pennsyl- vania, whereby a judge of quarter sessions can, on due complaint and evidence, commit a drug addict to any proper hospital or asylum for a period not to exceed one year, for care, treatment, and cure. The defect in this law is that no provision is made for indigent addicts, a provision that is made in the law providing for the erection of a state insti- tution for the treatment of alcohol and drug in- ebriates. Revision of the habit act in conformity with the special act governing the proposed insti- tution has already been prepared whereby the drug addict, if indigent, will be taken care of at the expense jointly of the state and of the county from which he comes. Now, as regards this proposed institution, the matter is in the hands of a commission, and they have purchased a tract of ground in Cumberland county, 524 acres in extent, and there remains in the treasury approximately135,000 for the prepa-
ration of this ground, the erection of buildings,
etc., but no appropriation has been made for the
maintenance of the institution once it is built. Plans
have been drawn by the engineering division of the
Department of Health, which provides for the

erection of buildings on this tract that would cost
not to exceed 150,000. That is as far as the matter has gone W the present time. In connection with it, I was instructed to make a survey of public institutions throughout the United States, and , 1 rendered a lengthy and elab- orate report on this subject. This report, which aimed to give nothing but facts, was somewhat discoiiraging, owing to the fact that practically every effort made as regards the conduct of a' public institution designed exclusively for the treatment of alcohol and drug inebriates has been a failure, and, at the present time, these special institutions have been closed. There are many reasons that may be assigned for failure, the principal one being incompetent •management, due to insufficient salaries being paid to the personnel. Another and a very important reason for failure was that practically all of these institutions admitted persons on volun- tary commitment, which has universally been an entire failure. The only form of commitinent at all effective is a legal commitment whereby the inmates are brought under absolute control. There are also certain psychological reasons promoting the failure of these institutions, but the ^ greatest one of all is the fact that these people, when cured, as -quite a large proportion of them are, almost immediately revert to their habit again, once they are discharged. So far as I have been able to fol- low up the patients who have been discharged from such institutions as cured, I think I am able to say that ninety per cent, of- them lapse within six months. Therefore, there is little encouragement \in opening public institutions until after the laws are ^o drafted and their administration so definite that the great quantities of unnecessary narcotics" in the hands of the more ignorant element in the medical profession, and in the hands of peddlers as well, are shut off. I am obliged to say that comparatively little permanent success has resulted from the treatment of the psychotic class of addicts, except in the psy- chopathic wards of hospitals for the insane, and there, in Pennsylvania and elsewhere, quite a degree of success has been attained. I do not wish to be regarded as lacking at all in humanitarianism, but from two years' practical experience in administering the Pennsylvania law I am forced to the conclusion that too much senti- mentalism is indulged in as regards the drug addict. The physician sees him only in his personal relation- ship with him, while the Bureau of Drug Control sees him in his relationship with the almost inevit- able two, three, or four doctors treating him at the same time. The physician who has registered the drug addict under Section 8 of the Pennsyl- vania law is usually honest. The addict rarely is, and I must confess that of the thousands of addicts of various classes registered in the Bureau of Drug Control as under the care of private practitioners, not two per cent, of them have been cured, though a much larger proportion have been reported as cured. These supposedly cured persons almost inevitably appear on our records again, so that so far as the treatment of addicts by the private phy- sician is concerned, I am most pessimistic. There 54 ROSENBLUTH: EAR CONDITIONS IN AMBULATORY PATIENTS. ^'"""^ Medical Journal. are, of course, a few physicians temperamentally adapted to the handHng of these cases, but these physicians are few indeed. The man whose sym- pathies are practical instead of on the surface, who has a hard fist and controls with a rod of iron the addicts imder his care, may succeed. The average practitioner makes a gloomy failure in his efforts to control the drug addict. Therefore, it is no wonder that it is demanded that institutional care be provided for these people. From my careful study of the situation, I am much opposed to the building of a large and elab- orate institution for the exclusive care of drug addicts. I do not think it possible, under present conditions, for such an institution to be a success, for reasons that would require a long paper of itself to elaborate. In general, it may be said that the- grouping together of drug addicts in an insti- tution brings about much the same results as their grouping together in any section of a city, and whatever care is provided after they are taken off the drug, which is a very easy matter with the average addict, this care must be of a nature to build them up physically, mentally, and morally, increasing their power of resistance. This involves industrial work, and a life under proper environ- ment. I am, therefore* of the opinion that the special institution provided for should be a small one. largely industrial, the inmates kept under absolute control, legally committed, and arrested ancf brought back if they escape. Furthermore, I would have committed rd such an institution only the hopeful cases, and those who, after hospitaliza- tion and being successfully taken off the drug, need a period of building up nnder proper environment, with a reasonable degree of physical work. As involves the element congregated in certain sections of our cities, the addicts who are in jail and out again, off the drug and on again, who drift from place to place, committing crime and becoming more and more vicious, this class of per- sons, in my view, should be put in houses of cor- rection, or work houses, and compelled to earn their way. I am wholly out of sympathy with senti- mental views concerning these people. They are a drag on society, worthless to themselves and to the state, and they drift to the cities away from smaller communities where control is more easy, adding to the already vicious element in the slums, and becoming a menace to themselves and society at large. To spend sympathy and large sums of money on these people in the following out of idealistic methods of control is entirely futile. They are a police problem and the municipal police and health officers should cooperate in breaking up all of the nests of vice these people inhabit, putting them under such definite restraint that it will become generally known throughout the vicious element that drug addiction, for which there is no justification from incurable disease existing in the j)erson, is a vice, if not a crime, and will be con- trolled the same as other vices and other petty crimes. As involves the legal control of the drug peddler, the federal laws are adequate, but their enforce- ment is difficult and the personnel employed is altogether too small to accomplish results. With amendment proposed to the state law, we should be able to do more in the future than we have accomplished in the past. My own personal view is, as regards these people, to organize a man hunt, rim them down like rats to their holes, dragnet the sections that they inhabit, show them no quarter, hunt them out without fear or favor, and punish every one of them arrested to the full extent that the law permits. It is only by such radical treatment and educating the community to the point of view that these are the lowest and most debased class of 'criminals, worthy of nothing but the full and rigid enforcement of the law, that we will stamp out this menace. These people are not the class played up in fiction as picturesque characters, brilliant and full of mental resource; on the contrary, they are a debased and sordid lot, cunning to the last degree, unprincipled and full of vicious resource; but with an adequate enforcement of the law, not only by the officers specifically charged with the enforce- ment of the drug laws but also by every policeman and constable in the state, they can be suppressed, and it is necessary to cultivate public opinion to the point of justifying this sweeping and radical enforcement of the drug laws against this class of people. REFERENCES. Traffic in Narcotic Drugs, U. S. Treasurv Department 1919. 403 North Second Street. SERIOUS EAR CONDITIONS AND COM- PLICATIONS IN AMBULATORY PATIENTS.* By M. Rosexbluth, M. D., New York, Eye Department, Vanderbilt Clinic; Ear Department, Manhattan Eye, Ear, and Throat Hospital; Chief of Out Patient, Ear, Nose, and Throat Department, Lebanon Hospital. When a life endangering complication develops in the course of a disease, the patient usually becomes too sick to continue as an ambulatory patient; in fact, our suspicion that a serious complication has developed in an ambulatory patient is usually aroused by the fact that, with more or less sudden- ness, symptoms have appeared that completely incapacitate him and force him to bed. So gener- ally true is it that dangerous complications announce their presence by making the patient very sick that not only the layman but also a large proportion of medical men often fail to suspect or recognize their existence, just because the patient is walking about and does not complain very mtich or at all. The ear, more than any other organ of the body, is prone to the development of grave complications with which the patient may still be up and about, in constant danger of losing his life as a result of it. Many patients die every .year from such com- plications which were either never recognized at all or recognized too late, or were only accidentally discovered at the autopsy. Many of these patients might have been saved if the condition had been o •Read before the Bronx County Medical Society, February 18, 1920. Janu.-.ry s, 1921.] ROSENBLUTH: EAR CONDITIONS IN AMHULATORY I'ATIENrS. 55 recognized in tirhe, when proper treatment could still have been effective. For that reason it is important for us to do two things : First, recognize that there are many such serious life endangering ear complications that may exist in patients who are still walking about. Secondly, acquaint our- selves with all symptoms that point to or even faintly suggest the development of such a compli- cation, so that by timely intervention the patient's life may be saved. These complications can be divided, on an anatomical basis, into three groups, as follows : 1. Those developing in the middle ear and mastoid, including the venous sinuses ; 2, those developing in the labyrinth ; 3, those developing in the brain, in- cluding meninges. MIDDLE EAR COM PLICATIOXS. Cholesteatoma. — This is the name given to the mass of debris made up in the cavity of the middle ear, consisting of broken down bone, epithelial cells and secretion,- with cholesterin crystals. As this mass grows it causes the absorption of the bony wall of the middle ear cavity against which it presses. In this way it may break through the tegmen tympani and produce intracranial complica- tions, i. e., meningitis or brain abscess ; or, by pro- ducing absorption of the bony capsule of the laby- rinth it may produce a fistula in the labyrinth or an acute diffuse labyrinthitis ; or it may produce a sinus phlebitis through caries or necrosis of the sinus plate of the temporal bone. They may exist for years without any symptoms, or may produce a feeling of heaviness and pressure on the corre- sponding side of the head, headache, and dizziness, without the presence of any acute inflammatory phenomena. The diagnosis is made positive when, on microscopical examination, the small gritty lumps that come away in the irrigating fluid are found to possess the characteristic cholesteatomatous ap- pearance and structure. Treatment is radical mastoidectomy. Facial paralysis. — Facial paralysis of otitic origin is next to be considered, not only because to the patient it is a very serious matter when half the face is paralyzed, but also because when this paraly- sis is of otitic origin, it is sometimes the expression of a very serious bone necrosis taking place in the middle ear. For that reason when a facial paralysis occurs in a person who has a chronic running ear, it is very important to determine whether it is of the ordinary rheumatic type, which is not dangerous to life, or whether it is of otitic origin, when it is the expression of a life menacing pathological condition. The differentiation can nearly always be made by doing a caloric test on the labyrinth of the sup- purating ear. If it is of otitic origin, the labyrinth will be "dead" and nonfunctionating, so that douch- ing the ear with cold water (68° F.) will not pro- duce nystagmus to the opposite side, nor with warm water (110° F.) produce nystagmus to the same side, because on account of the close proximity of the semicircular canals, particularly the horizontal one, to the horizontal portion of the facial canal, the labyrinth has nearly always been destroyed by the same process of bone necrosis that has pro- duced the facial paralysis. i he indication is for a thorough radical mastoid operation plus labyrinthec- tomy. In contradistinction, a facial paralysis oc- curring with an acute middl? ear condition is not of grave significance. It is then gcneraUy due to a dehiscence in the bone of the facial canal, and disappears with the subsidence of the middle ear condrjion. I'>u)ic necrosis. — This is another serious condition. Its existence can be supposed when, in a running ear, there is the development of pain, most intense at night, persistent foul discharge, and granulations. The diagnosis is positive if carious bone can be seen or felt with the probe, or sequestra are discharged. These sequestra not infrequently are made up of one or more ossicles, portions of semicircular canals, or cochlea. Such a process often leads to intra- cranial complications and calls for a thorough radical mastoidectomy, if the labyrinth is still unin- volved ; if it is involved, a labyrinthectomy must also be done. Mastoid complications. — A subperiosteal abscess may exist in a patient who is still ambulatory, and even an acute mastoiditis may develop with little disturbance to the patient throughout the whole course of its development. In chronic running ears chronic mastoiditis not infrequently occurs, where at operation the mastoid is found infiltrated with pus or granulations, or is sclerotic. These are dangerous conditions, because they may give rise to sinus thrombosis, meningitis, brain abscess, or laby- rinthitis. Sinus disease. — In connection with the sinus,' the patient may be walking about with a perisinou,s abscess, presenting only a few symptoms of a mild grade of infection, or no symptoms at all, when, as often happens, the sinus is protected by a thick wall of granulation tissue. A swelling of the mas- toid over the region of the emissary vein, when present, is characteristic. Sooner or later it will invade either sinus or cerebellum, or both, if not attended to. Besides this, patients sometimes walk about with actual sinus thrombosis, with chills and fever, and such cases have been incorrectly treated, for malaria or miliary tuberculosis. LABYRINTHINE COMPLICATIONS. Labyrinthitis. — Perilabyrinthitis and circum- scribed labyrinthitis may manifest themselves in attacks of dizziness ; or there may be a labyrinthine fistula which also is marked by attacks of dizziness, but where, in addition, the fistula test is positive, a nystagmus being produced by a sudden increase of the air pressure in the middle ear. Then there may also exist a latent diffuse sup- purative labyrinthitis, where, although the patient has no symptoms, the diagnosis can be made from the fact that the patient has total end organ deaf- ness and that the static labyrinth gives negative reactions to the caloric test. The existence of this condition is very dangerous. Latter day knowledge of this subject has taught us that it very frequently is responsible for meningitis or brain abscess, and also that many of the cases of meningitis that formerly seemed to develop in some obscure way and carried oif the patient- after a mastoid operation, were the result of the extension of this latent sup- 56 GILBRIDE: WOODY OR LIGNEOUS PHLEGMON. [New York Medical Journal. purative process in the labyrinth to the meninges. Nowadays, every careful ear surgeon does a caloric test on the ear to be operated on for radical mas- toid, to determine the existence of labyrinthine reactions in the ear and thus exclude the existence of a latent suppurative process in the labyrinth ; if this test elicits no reactions from both the horizontal and vertical canals of the ear about to be operated upon, a radical mastoidectomy would be insufficient ; a labyrinthectomy would also be necessary. BRAIN COMPLICATIONS. Abscess in the brain. — In connection with the brain there may exist in ambulatory patients, either an abscess in the cerebrum or a cerebellar abscess. Their existence may never be known when of small size, or sometimes even when of fair size, until accidentally discovered at autopsy after the patient has died either from some other disease or from rupture of the abscess into the subdural space or ventricles. At other times the patient may walk around with symptoms directing suspicion to the existence of an abscess in the brain, as, for in- stance, headache, various degrees of change in the appearances of the disc, usually neuritic in type, and more frequent in cerebellar than in cerebral abscess ; and in cerebellar abscess also nystagmus, ataxia, and interference with the normal pastpointing reaction, on testing the labyrinth, in the extremities of the same side as the afifected cerebellar hemisphere. In such patients we may be able to get the corrobora- tive history of the initial stage or stage of develop- ment some time back. Macewen states that at this stage there is always a chill or rigor, high tempera- ture and severe headache. The symptoms are of short duration, the fever and headache subsiding in a few days, leaving the patient in good condition, or perhaps immediately followed by symptoms of intracranial pressure. This stage is unquestionably often supposed to have been la grippe. Meningeal involvements. — In the meninges the following conditions may exist in an ambulatory patient: Chronic pachymeningitis, whose existence is discovered at autopsy when the patient dies from an extension to the pia or from some other disease ; extradural abscess, when sacculated, the diagnosis is very difficult or impossible. A helpful point is the coming and going of threatening symptoms of meningeal irritation after a sudden discharge of a large quantity of pus from the ear. If left to itself, it produces fistulse in the dura with leptomeningitis running a rapidly fatal course. Pachymeningitis externa : By this term Politzer designates the con- dition observed in large perforations of the tegmen tympani and confined to the outer surface of the dura. It really does not differ from an extradural abscess. It may exist without any symptoms. One finds, sometimes, at the radical operation, quite ex- tensive areas of the dura of the middle cranial fossa lying freely exposed and covered with thick granu- lations or exudate without any previous symptoms of meningeal irritation. These are the serious ear conditions and compli- cations that may exist in a patient who is still up and about. Perhaps some other conditions might also properly have been included under this heading. Of course no attempt was mad^ to draw a com- plete clinical picture of the way in which every condition mentioned presents itself at all times. When present, many of these conditions frequently, and some generally, produce such marked symptoms and make the patient so desperately sick that it is inconceivable for the condition at such time to be unrecognized or at least suspected. It is the inten- tion of this paper to call attention to the fact that so many serious ear conditions and complications may exist with little or no disturbance to the patient, and to call attention to those few symptoms when present at such time, a recognition of which will help diagnose or direct suspicion to the exist- ence of the condition which may often mean the saving of a life. And because so often patients with these conditions do not connect the symptoms with their ear condition and apply to the general practitioner for relief, it is the duty of the general practitioner to acquaint himself with the symptoms of these conditions in the ambulatory patient, so that he may not overlook their existence. He should also always bear in mind that a patient who has a chronic running ear presenting symptoms of whatever nature, unless very evidently accounted for by 'Some disease entirely unconnected with the ear, is safest in the hands of an otologist trained to recognize this con'dition and its complications. 31 East Seventy-second Street.. WOODY OR LIGNEOUS PHLEGMON OF RECLUS.* With a Report of Two Cases Occurring in the Thigh. By John J. Gilbride, A. M., M. D., Philadelphia, Pa. Reclus in 1893 first described a hard swelling that occurred in the neck, and in his publication he reported five cases of what he called woody or ligneous phlegmon. Woody phlegmon is a chronic inflammation affecting connective tissue, fascia and muscles. It is characterized by extreme hardness which shows little tendency to suppurate. While -in the cases reported by Reclus the phlegmon occurred in the neck, that author stated that the condition could occur in the right iliac fossa. In three cases reported in the literature it occurred during the course of chronic appendicitis. One of the patients, whose history I shall give, had chronic appendicitis. Appendectomy was performed, which was followed in six months by woody phlegmon of the left thigh and this in turn was followed by acute osteomyelitis of the right femur. Many, if not most, of the cases reported in the literature are those where woody phlegmon occurred following operation. This latter aspect of the disease has been described and a full bibliography given by W. W. Grant, of Denver, Col. (1). Fasana (2) records cases where the disease occurred in the foot and in the gluteal region. Previous ill health and trauma are predisposing causes and the disease occurs generally after middle *Read before the Philadelphia County Medical Society, November 26, 1919. January 8, 1921.] GILBRIDE: WOODY OR LIGNEOUS PHLEGMON. 57 life. However, a number of cases have been re- ported vi^here it occurred in individuals fifteen or twenty years of age. The exciting cause is infec- tion with or without trauma. Bacteriological ex- aminations made in these cases have shown that many varieties of bacteria have been reported present, all of attenuated virulence. Duse (3) reports the case of a boy fifteen years of age, in whom woody phlegmon occurred in the left upper abdominal quadrant two and a half months after an infected herniotomy wound had healed, and records the following observation : Incision was made the full length of the growth ; no pus was found but a pale rose colored fluid was discharged. Tissue removed for histological ex- amination showed inflammatory new growth with some leucocytes and many plasma cells. Cultures showed small, white gram negative staphylococci which produced no effect on animal inoculation. The patient left the hospital with general and local conditions unchanged. The author states that in previous studies the following bacteria have been reported, namely, Klebs-Loeffler bacillus, pseudo- diphtheria, streptococci, bacillus proteus, staphylo- cocci, white and yellow, all of attenuated virulence. Todd, of St. Joseph, Mo., has reported a case of woody phlegmon that occurred in the abdominal wall of a young woman. It was supposed to be due to a fall in 1909. This tumor of boardlike hardness was first observed in March, 1910. An operation was performed, removing the central part of the tumor on May 16, 1911, with no appreciable improvement. The patient had lost twenty-one pounds in weight in one year. On account of the loss of weight and her weakness a diagnosis of sarcoma had been made, which later proved to be an error. The pathological report showed inflam- matory changes in the muscle with a large amount of granulation tissue lymphoid plasma cells and polymorphonuclear leucocytes, complicated with tiny abscesses. Charles A. Powers, of Denver, Col., has described this condition (5). The onset of woody phlegmon is gradual and its progress is slow. A hard, indurated swelHng is noticed, which progressively extends. Its outline is sharply defined, but. according to Fasana (2), it may be diffuse or nodular. The usual signs of acute inflammation are absent. Swelling is present, but there is no redness of the skin, little or no pain or tenderness, and fever is slight or absent. The skin is involved late, if at all, in the course of the disease. The hardened indurated area increases very slowly over a period of months or even one or two years. Its occurrence in the neck is of more serious import than when it occurs elsewhere in the body. This is true not only on account of the complications which may arise in the neck, but also on account of its extension. There is little ten- dency to suppurate, which would be the most fortu- nate outcome in terminating the case. Both of my patients believed they had rheuma- tism. The masses were not connected with the bone, periosteum, or skin ; lymphatic involvement was not demonstrable. Grant says the lymph nodes are not usually affected. Fasana (2) uses the term hyperleucocytosis, and says that its presence is in favor of a diagnosis of phlegmon. In the early stage of this condition it has been mistaken for cancer or sarcoma. The possibility of lues, actinomycosis, and tuberculosis, must also be borne in mind. One can readily appreciate the difficulty of making a differ- ential diagnosis between woody phlegmon and sarcoma. This is especially -true in cases in which the onset has been insidious, or where there has been a history of trauma. The cases which follow operation should be less confusing. The histories of my cases are as follows: Case I. — Female, white, married, fifty-one years of age, born in the United States, housekeeper by occupation. She consulted me on January 3, 1917, because of pain in the right thigh and leg, which was increased by walking. Her previous history was negative, except that she had had an attack of acute appendicitis in September, 1916, and was confined to bed for one week. Her bowels were constipated, and "she always had a bad stomach." Pain in the right thigh was worse at night. Physical examination did not show any tenderness over the course of the anterior crural or obturator nerves ; the posterior branch of the latter pierces the capsular ligament and sends branches to the knee joint. Neither was there tenderness along the course of the sciatic nerves. Full extension of the right leg and thigh caused slight pain in the right lower abdomen. There was tenderness at McBur- ney's point. Urine was negative, blood pressure 130 mm. systolic, 80 mm. diastolic. A diagnosis of chronic appendicitis was made. I performed an , appendectomy on the patient at the Medicochirur- gical Hospital on January 27, 1917; recovery was uneventful. The patient consulted me again on October 10, 1917, complaining of a large mass in the inner side of the left thigh. Her attention was first called to this condition by the presence of slight pain in the left thigh in June, 1917. Later in September and again in October of the same year she had been under treatment by her physician for rheumatism. The mass in the thigh had been increasing in size and caused her some alarm. On examination I found a large swelling, nearly twice the size of my fist, in the inner side of the left thigh. The mass was slightly movable and nowhere adherent. The skin was normal in color. I made a diagnosis of chronic inflammation, bearing in mind the possi- bility that the mass might be malignant, i. e., sar- coma. There was no sign of suppuration. The patient hesitated about permitting an operation. However, she later consented, and on October 27, 1917, a deep incision was made into the mass. There was no pus, only a dark brown bloody fluid ; the wound was packed and dressed antiseptically. A culture taken from the wound showed staphylo- coccus pyogenes aureus. The mass gradually diminished in size. About November 10, 1917, she began again to have pain in the right thigh and leg. The pain was only intermittent at first, but later it became almost constant. She improved in a few days, and on November 15, 1917, the patient was able to be up and about the house, but on November 27, 1917, she was again confined to bed on account of the severe pain in the right thigh. The right 58 MADDREN: TRAUMATIC INTRAMUSCULAR OSSIFICATION. [New York Medical Journal. femur, especially uver tlie lower end of the shaft, was tender to pressure. Her temperature at that time was 101° F., and there was an increase in leucocytes. A diagnosis of acute osteomyelitis of the right femur was made and operation advised, but the patient refused to give her consent until December 16, 1917, when I operated on the right femur at the RIedicochirurgical Hospital on Decem- ber 17, 1917. A small abscess containing about a fourth of an ounce of pus was exposed at the jimc- tion of the lower and middle third of the right femur. Culture from the abscess showed Staphylo- coccus pyogenes aureus. Recovery was slow ; the wound healed by February, 1918. An autogenous vaccine was made and used in her case. She has since remained well. Since the appendectomy she has not had any further trouble with her stomach and she also said that the head- aches from which she had suffered several times a week for years past had also disappeared. Case II. — Female, white, married, aged thirty- five, born in the United States, housekeeper. She consulted me on July 15, 1917, stating that about two months before she had noticed a swelling in the right thigh, which had been gradually getting larger, so that she had difficulty in walking. She was a rather delicate woman, and poorly nourished. Examination of the mass in the thigh showed it to be about the size of an orange. The color of the skin was nor- mal. The mass was movable, slightly tender, and nonadherent. None of the signs of acute inflam- mation were present, and there was no lymphatic involvement. The mass was incised and drained. Culture showed staphylococcus pyogenes aureus. In the course of two weeks the mass had disap- peared. Before the operation I gave her an injec- tion of ten thousand units of diphtheria antitoxin. She also was given an autogenous vaccine. Case III. — Female, white, aged thirty-six years; married, no children, housekeeper by occupation ; born in the United States. She was referred to me in February, 1901. She had a hard, boardlike, in- durated mass in the left lower abdomen, involving the abdominal wall and extending into the left iliac fossa. It was regular in outline and there were no signs of acute inflammation. The woman was pale, weak, and very poorly nourished. She had lost about twenty-five pounds in weight during the pre- vious three months. Her appetite was poor and her bowels were constipated. There was a slight elevation of temperature — 99.2° F. — pulse rate 84 a minute ; uranalysis was negative ; hemoglobin seventy-six per cent. (Dare). Pelvic examination showed that the uterus was not involved. Although at that time I did not know anything about woody phlegmon, I made a diagnosis of inflammatory in- duration due to a low grade infection and probably having its origin in the sigmoid flexure of the colon. I expected on making an incision to find pus deeply situated, but did not discover any foci of suppu- ration. I then concluded that the mass was malig- nant. However, after subsequently learning some- thing aboi.it woody phlegmon, I was satisfied that this was the correct diagnosis. The patient had been confined to bed for six weeks before I saw her; she died five weeks later; no autopsy. TREATME.VT. Extirpation may be attempted, if practicable, but it is rarely practicable. In the event of being unable to extirpate the mass, free incisions should be made into the mass, also around its periphery. These latter incisions are made for the purpose of limiting the extending area and also as an aid in promoting absorption. In these cases hot, moist antiseptic dressings should be used, and over the dressings a hot water bottle applied, which should be changed at frequent intervals. An autogenous vaccine should be made and injected. One should give special at- tention to the hygienic, dietetic, and medicinal treat- ment, as these patients are usually in a weakened and poorly nourished condition. Preparations of iron and arsenic are valuable. From what we know of this disease, its course is very prolonged and the disease may be serious, especially when the neck is involved. Should I encounter another case of woody phlegmon I shall employ blood transfusion, which I believe would be valuable. I injected diphtheria antitoxin in one of these patients and it brought about a marked improvement. The disease appears insidiously ; it follows operations, especially abdominal operations, and it may be caused by the presence of a foreign body. REFERENCES. 1. Grant, W. W. : Ligneous Phlegmon of the Abdomi- nal Wall, Journal A. M. A., April 5, 1913, p. 1039. 2. Fasana : Gacctta degli ospcdali e elle Cliniche, Oc- tober 20, 1912, p. 1345. 3. DusE : Contributo ullo Studio del flemmone lignes di Reclus, Gacctta denli ospedali e elle Cliniche, 1910, xxxi, p. 625. Quoted by Grant. 4. TonD, Luther Anson : Obscure Infiltration of the Abdominal Wall, Journal of the Missouri Medical Associa- tinu. February, 1912. 5. Powers, Charles A. : Woody Phlegmon of the Neck of Reclus, Journal A. M. A., July 29, 1911, p. 365. 1934 Chestnut Street. TRAUMATIC INTRAMUSCULAR OSSIFICATION. By Russell F. Maddren, M. D., New York. The term traumatic intramuscular ossification was first used by Morley (1) in reporting a case of what is often called traumatic ossifying myositis. Morley took exception to the old name because • it implied an unfounded pathology for this interest- ing lesion, and in his article he brought forward experimental pfoof of the correctness of his clinical deductions. Traumatic intramuscular ossification is the rather uncommon seqitence of a single severe contusion. In not one of the two hundred cases collected by Shere (2) was there any break in the skin. It should be sharply dififerentiated from true myositis ossificans of the progressive type that starts early in life, usually in the muscles of the neck or liack, and progresses irregularly and intermittently. There is also a third type of muscle and tendon ossification which is the result of slight but fre- c|uently repeated trauma. REPORT OF A CASE. History: On March 31. 1920, S. M. (No. 293), aged twenty-five, a blacksmith's helper, reported to January 8, 1921.] MADDREN: TRAUMATIC INTRAMUSCULAR OSSII-ICATION. 59 me, complaining of lameness and severe pain in his right leg. He said that while holding a heavy swage under a steam hammer his hands had slipped just as the hammer came down. The handle of the >wage, torn from his grasp, struck him so forcibly on the front of the right thigh jthat he was felled. He got up unaided and was able to bear his weight on his right leg, but walking caused severe pain. Examination: There was an area of tenderness at the lower anterior part of the, right thigh, and some swelling. Partial or complete fracture of the femur was ruled out by the use of the fluoro- scope and by comparative mensuration of both legs. Diagnosis, contusion. Course: The man was transported to his home and treated there until April 8th. The treatment used was rest, elastic compression, and first cold and subsequently hot applications. Both the pain and the lameness gradually disappeared, and on April 8th the patient returned to his work.. He was dis- charged, cured, on April 12th. Second examination: On April 28th, S. M. re- ported again, complaining of pain in his right thigh and inability to flex the knee completely. There had been no additional trauma. Upon examination a firm, sensitive, immovable mass about the size of an egg could be distinguished. It appeared to be growing from the femur about six inches above the patella and a little to the outer side. His tem- perature was normal. Tests and examinations for tuberculosis and lues were negative. A skiagram showed a mass of new bone three and a half inches long by one and a half inches thick, at about the middle of the femur, but the picture did not appear to be that of ossifying periosteal sarcoma. A print of the X ray plate was submitted to Dr. James Ewing, of New York, who said that he did not think the lesion was malignant. He advised against excising a part of the mass for microscopic diagnosis. Course: For ten days cacodylate of soda was given subcutaneously every other day in increasing doses. Commencing on May 3rd, x ray treatments were started and repeated twice a week in as heavy doses as was considered safe, and at the same time the patient was put upon potassium iodide three times daily. Probably this treatment had very little eflfect upon the lesion. The man was kept very quiet at home until June 7th, by which date tender- ness had almost disappeared and he returned to light work. Passive motion was gently forced every day and he was encouraged to exercise his leg. Another skiagram on June 28th showed approxi- mately the same condition that had been found previously. The mass was no larger. By the middle of July the leg could be flexed to a right angle and the man was working regularly at his trade of blacksmith's helper. PATHOLOGY. Morley called attention to the fact that under certain conditions a severe blow might loosen the pferiosteum from its bony attachments, lacerating and contusing it in the process. In his original article he showed pictures of traumatic intramus- cular ossification experimentally produced in the rabbit. At the same time that the periosteum is injured the overlying muscle is contused and some of its fibres are torn. Bleeding occurs from the denuded bone and torn periosteum, and osteoblasts in a free and possibly ameboid state pass out from the bone and find in the mixture of pulped muscle and extravasated blood an almost ideal culture medium wherein they thrive and produce new bone. The mass of new formed bone may be small or may be so large as to occupy almost the entire muscle in which it lies. In Outland and Clenden- ing's case (3) the area of ossified tissue measured ten inches by three inches by two inches. BIOLOGY. In the records of the German Army over a period of ten years, Schultz (4) found 233 cases of trau- matic intramuscular ossification. The most inter- esting and curious fact that his research brought out was that, of these cases, in all but three the lesion was either in tlie quadriceps femoris or brachialis muscles. (Of the three exceptions, two were in the masseter and one in the pectoralis major.) The highly specific localization exhibited in these cases is probably due to the fact that nowhere else in the body excfept in these two particular places can there be found a considerable area of easily detached periosteum overlaid by a thick pad of muscles. Murphy (5) points out that in both of these regions there is a "broad, smooth, convex area of bone, covered by periosteum, that is loosely attached and readily srtipped oflf owing to the absence of tendin- ous insertions." DIAGNOSIS. According to Bloodgood, myositis ossificans seen before bone begins to be formed can only be dif- ferentiated from sarcoma under the microscope. It is improbable, however, that a patient could be induced to consent to disarticulation at the hip joint a few days after having bruised his thigh however severely. A month or more after the injury the character of the lesion can be better established by a skiagram than by a microscopic section. Occasionally severe contusions are followed by an aneurysmal type of sarcoma, but these cases usually present such a striking clinical picture that they could not be confused with anything but ful- minating osteomyelitis, which they simulate exactly until pulsation becomes palpable. I have seen one such sarcoma prove fatal in twenty-eight days from the. original injury. Socalled rider's bone and the ossific deposits sometimes found in the deltoid muscles of infantry soldiers are both the results of frequent slight mechanical irritation and are true occupational diseases. In the progressive type of ossifying myositis, the first complaint may have been of painful swellings in the muscles of the back, neck or thorax, but the differential diagnosis is usually very easy. Accord- ing to DeWitt (6) and others, .seventy-five per cent, of such cases show microdactylism. This peculiar- ity, first noted by Helferich in 1879, was not present in the only case of the multiple progressive type that I have had the opportunity of studying. 60 IaXDSMAN: diagnostic VALUE OF PROCTOLOGIC AL EXAMINATIONS [New York Medical Journal. TREATMENT. Unless serious disability exists and persists un- improved by active and passive exercises, surgery is contraindicated. In 1905, R. Jones (7) advised operation in all cases of traumatic intramuscular ossification, but in a letter to Rickman Godlee (8) in 1911 he said; "The simplest looking mass in the bend of the elbow is a difficult problem to deal with surgically, and more than once I have wished that I had let it alone." If operation is decided upon, the physiology of bone must be remembered. Simple excision is almost certain to be followed by recurrence, because the normal periosteum has been torn loose and no longer fulfills its function as a limiting membrane for osteoblasts. In Morley's case there was a recurrence in three weeks. At the second opera- tion he successfully transplanted fascia lata onto the denuded bone to prevent adhesions between bone and muscle and to form an artificial limiting membrane. If not operated upon, the mass usually ceases to grow after a time and may even become smaller, owing to reabsorption of bone similar to that seen in some cancellous osteomata (9). Treatment with radium, the rontgen ray, or potassium iodide, may possibly accelerate this process of consolidation, and does no harm if carefully controlled. The patient should be encouraged to exercise in an attempt to restore the normal range of motion. Very fre- quently vigorous exercise leads to complete func- tional recovery after a considerable lapse of time. REFERENCES. 1. MoRLEY, J.: Traumatic Intramuscular Ossification, British Medical Journal, xi, 1475-77, December 6, 1913. 2. Shere, O. M. : Myositis Ossificans Traumatica, Jour- nal A. M. A., Ixv, 1012-6, September 18, 1915. 3. OuTLAND, J. H., and Clendening, L. : Recurrent Myositis Ossificans Traumatica, Interstate Medical Journal, xxii, 2, 1093, November, 1915. 4. ScHULz, H. : Ueber Myositis ossificans in der Armee, 1897-07, Deutsche Milit'drartsl. Zeitschrift, xxxix, 4, 129-45, 1910. 5. Murphy, J. B. : Traumatic Intramuscular Ossifica- tion, Surgical Clinics, vol. v, No. 4, 765-771, 1916. 6. De Witt, L. : Myositis Ossificans, American Journal of the Medical Sciences, cxx, 295, September, 1900; Nico- LAYSEN : Norsk Magasin fiir Lagevidensk, xv, 4, 1900. 7. Jones, R. : Archives of the Rontgen Ray, 1905 (cited by Godlee). 8. GoDLFE, R. : Myositis Ossificans, Proceedings of the Royal Society of Medicine, Series of 1910, 154. 9. Battle and Shattock : Cancellous Osteomata, Pro- ceedinqs of the Royal Society of Medicine, Series of 1908, 83. 616 Madison Avenue. Specific Diagnosis and Treatment of Acute Lobar Pneumonia. — Lesley H. Spooner (Boston Medical and Surgical Journal, February 26, 1920) says that thirty per cent, of the cases of acute lobar pneumonia are due to Type I organism. An im- mediate diagnosis of type is essential for the early administration of specific sera. The use of poly- valent sera is irrational and unjustified. Careful use of Type I senmi in Type I pneumonia is safe, and has reduced the spread of the disease process and the mortality to a sufficient extent to indicate its universal application. PROCTOLOGICAL EXAMINATION AS AN AID TO GENERAL DIAGNOSIS. By Arthur A. Landsman, M. D., New York, Associate Surgeon, Diseases of the Rectum, Post-Graduate Medical School and Hospital; Attending Rectal Surgeon, Jewish Memo- rial Hospital; Deputy Surgeon, Diseases of the Rectum, Out Patient Department, New York Hospital, etc. The full objective of a local examination is not attained by the determination of abnormality or disease in a suspected organ or area, or its exclu- sion therefrom; if such an examination is to fulfill its best purpose, it must not end with the local findings, but should, if possible, serve as an addi- tional means of investigation of the disturbance, no matter where located. That certain general con- ditions produce definite and characteristic changes in remote organs not primarily concerned in the disease must be admitted. The well trained oph- thalmologist may readily detect the presence of some general conditions by an examination of the eyegrounds : indeed, he may thus be able to throw some light on the nature of the disturbance and even estimate its prognostic importance. While this may not apply in a like measure to all organs, it would seem reasonable to suppose that a profound systemic disturbance would leave im- pressions upon an essential organ which may be interpreted in terms of diagnosis because of their frequent association with definite pathological lesions elsewhere in the body. It is our firm belief that the science of proctology may at times be so utilized as an aid to diagnosis of general diseases, obscure and otherwise, by the discovery of changes in and about the anorectal parts, which may be regarded in some cases as pathognomonic of particular dis- eases, in others at least strongly presumptive of their presence. The first of these which suggests itself in this connection is syphilis, which has superior claims because of its importance as a social problern en- tirely aside from what- we know of its ill effects upon the health and well being of the httman race. It is particularly true of ihis disease that early diag- nosis is the means of preventing potential injury, in proportion as its delayed recognition spells disaster. Hence anything which may aid us in discovering its presence as early as possible must be a welcome addition to our defensive forces ; and it is an indisputable fact that careful proctological examination has more than once resulted in un- covering evidence from which a tentative diagnosis of syphilis has been made and confirmed later by the development of unmistakable symptoms. The primary lesion of syphilis is very rare in- deed about the anus and rectum, but when it does occur it is well to remember that it may fail to show its usual characters because of the physical conditions which exist in this region, having a ten- dency to modify and blur the classical picture (1) as the proctologist sees it. The anorectal chancre may take the form of multiple fissures or ulcers between the radial folds, with hypertrophy of the skin, maceration of the superficial epithelium, offen- sive discharge, and a swelling of the inguinal lymph glands. Simple nonspecific anal fissure does not January 8, 1921.] LA.WDSMAN: DIAGXOSTIC VALUE OF PROCTOLOGIC AL EXAMINATIONS. 61 generally exhibit these symptoms, hence in their presence the possibility of lues must be given seri- ous consideration, even in the absence of clinical signs which are known to occur in genital chancre. We had the opportunity of seeing one such case in a married woman who presented herself for treat- ment in our clinic for acutely painful radial ulcers at the anal margin, for which she had received pro- longed medical treatment without any marked suc- cess. Although they possessed the characteristics described above, which should have directed our attention to the true nature of the trouble at once, it remained unrecognized until some weeks later, when successive confirmatory symptoms made the diagnosis clear aiid led to admissions by the patient which disclosed the mode of the infection. Oval patches of macerated skin on the opposing surfaces of the buttocks, close to the anus, may occur as anorectal symptoms very early in the dis- ease, sometimes the only gross evidence of it. They are the socalled broad based condylomata, generally regarded pathognomonic of lues, and so distinctive in appearance that, once seen, their significance will not be easily overlooked. They are, however, not the only type of condylomata found about the ano- rectal region ; the acuminate variety, which are ex- crescences of the skin — histologically, pure papillo- mata — occur with relative frequently, but have been generally lield to be nonspecific. In an admirable ."^tudy by Creadick, of Yale (2), ten out of twenty gave a strongly positive Wassermann reaction, and we may yet have to revise our opinion con- cerning their etiology. The deposit of plastic material in the rectum which results in the thickening of the wall and narrowing of the lumen, produces characters which, if not spe- cific, are strongly suggestive of syphilis. Strictures of luetic origin are firm, smooth, and inelastic, with a tendency to become annular and to infiltrate the gut to a considerable extent. They form a large percentage of all strictures of the colored race. Occasionally the presence of nonspecific anorectal disease may indirectly lead to the discovery of lues in a person who never presented any evidence of it, as it did in one of our cases. The patient, a married woman with a negative history (3), came into the hospital for treatment of a chronic purulent rectal discharge which was found to be caused by a blind internal fistula. An operation was advised and attempted under local anesthesia. The manipula- tions disclosed a striking diminution of the pain sense in the tissues about the anus, below the lower half of the sacrum, to such an extent that they could be cut without the use of any anesthetic. A neuro- logical examination disclosed changes in the deep reflexes and pupillary phenomena which resulted in the establishment of a diagnosis of incipient tabes, based upon an old syphilitic infection. In another case, the patient, a woman, was sent to the hospital on account of recurrent attacks of severe bleeding of the rectum, complicated by loss of control of the bowel. The anal canal and rectum were relaxed to such an extent that they could easily be held open and inspected without the use of any instrument, and offered no resistance to the introduction of the finger. The skin surrounding the anus was moist and eczematous, the hair absent, the anal opening deep, sunken, fissured and funnel shaped, the mucous membrane ulcerated and bleed- ing. A diagnosis of ulcerative proctocolitis was made secondary to pederasty, which was indignantly denied by the patient. However, her .family physician gave the information later that she admitted unnatural coitus in an effort to prevent pregnancy (4). But syphilis is not the only disease which pro- duces recognized changes about the anorectal region ; in tuberculosis we have another which is responsible for more or less characteristic symptoms in the form of lesions which may be identified as a part of the .specific process. In most instances tuber- culosis is not primary about the anus and rectum, but appears as a secondary infection from a focus elsewhere in the body. IBut whether primary or secondary, soon enough it assumes clinical appear- ances which leave little doubt to the experienced eye as to its true character. Of the lesions which are best marked, ulceration about the perianal tis- sues, anal canal and rectum, and fistula in ano stand out prominently and present distinguishing features clearcut and impressive. Ulcerations about the anus may either begin in the skin around it or follow by direct extension of the process from the lower portion of the anal canal, especially in persons with pulmonary tuberculosis, active or latent. They present to the naked eye shallow, irregular, uneven lesions with a wormeaten base and thin undermined edges, a description which applies equally to ulcers of the mucous membrane, where, however, the ques- tion of dilTerential diagnosis between tuberculosis and malignancy is often puzzling. In the latter con- dition the ulcers have a tendency to become deep and craterlike, with raised edges and hard borders, imparting to the palpating finger the sensation of a firm, hard infiltration, altogether absent in lesions of tuberculous origin. Tuberculous fistula follows abscess about the anorectal region, which is caused by the tubercle bacillus or invaded by it secondarily. When it occurs in persons who present obvious signs of pulmonary tuberculosis, the diagnosis sug- gests itself readily enough and errors will be avoided ; but in a certain number of cases the fistula is the first and, for a time perhaps, the only mani- festation of the constitutional infection, in an indi- vidual who may present no frank signs of ill health. A tuberculous fistula, while it may for a time show no local signs of its true character, will sooner or later develop marks which will serve to distinguish it from the nonspecific variety (5). The external opening is relatively large, its mouth gaping and ragged, its borders bluish and undermined in every direction, and the surrounding skin presents every evidence of poor nutrition. Moreover, the parts soon begin to show the wasting incident to such a grave systemic infection : the buttocks lose their rounded contour and become flattened, the bony landmarks prominent, the anal cleft deep and sunken, the hair silky and long, the skin dry and scaly — changes which should at once arouse a strong suspicion that the fistula may be merely the local manifestation of a constitutional disease. Any prolonged resistance to the free return of 62 MEDICAL SOCIAL SERVICE. [New York Medical Journal. blood into the liver, whether from within or with- out, will in time cause dilatation in the course of the vessels as a compensatory process, despite the fact that under these circumstances a greater pro- portion of the blood from the rectal veins must be returned to the general circulation by way of the vena cava ; hence it is quite clear that a diagnosis of hemorrhoids is incomplete without an attempt to establish the underlying cause. This must sug- gest itself in such diseases as tumors and infections about the pelvis, malpositions and new growths of the uterus and adnexa, pathological processes any- where in the course of the vessels which interfere with the circulation, or diseases of the liver, such as hepatic cirrhosis, which obstruct the free flow of blood through it. Carried a step further, any long continued disease of other organs which causes a congestion of the hepatic circuit will secondarily produce interference in the portal circulation and may result in symptomatic hemorrhoids. Hence their frequent association with chronic gastric, cardiac, and nephritic affections. In normal health the rectal sphincters are in a state of tonic contraction and the anal opening is closed, more perfectly in the young and vigorous than the aged and feeble, to the extent that the introduction of one finger is all they will bear with- out painful reaction. Operators who are especially skillful may be able in some subjects to stretch the sphincters under careful local anesthesia, but it is the general experience that to dilate them thoroughly the patient must be deeply narcotized. In persons who suffer from spinal and cerebral disorders, how- ever, which interfere with the innervation of the sphincters, there may be an abnormal relaxation of these structures which should at once call attention to a possible disturbance of nervous origin; the same may be said of fecal incontinence as a symp- tom when it is not due to local disease or to a post- operative complication. Such extreme degrees of relaxation may occur in tabes, general paralysis of the insane, multiple sclerosis, cerebrospinal syphilis, neoplasms or injury affecting certain portions of the central nervous system or spinal cord ; patients presenting these symptoms are likely to be brought to the proctologist in the behef that the trouble is due to rectal disease. Hence, he should be pre- pared to understand the pathology of these ctnidi- tions in order to classify them properly and refer them to those best able to treat them. Subjective sensations about the anorectal region are of interest in connection with the diagnosis of general diseases, but cannot be discussed in greater detail here. Enough has been said to show that because of the intimate relations of the various organs of the body, disease of one is likely to pro- duce physical changes which may be viseful in diag- nosis because of their frequent association with certain pathological states. RFFERENCES. 1. Lynch : Diseases of the Rectum, p. 283. 2. Creadick : Journal A. M. A., October 16, 1920. 3. S. H. : Liecords of Rectal Clinic, New York Hos- pital, Dr. Pool's Service. 4. N. P. : Records of Rectal Clinic, New York Hos- pital, Dr. Pool's Service. 5. Hill and Lani)SM.\n-: Journal A. M. A., March 22, 1919. MEDICAL SOCIAL SERVICE IN DISPENSARIES.* By the Public Health Committee of the New York Academy of Medicine. I. BRIEF HISTORICAL ACCOUNT. Medical social service, which began in this coun- try in Boston a decade and a half ago' to enhance the efficiency of hospital medical work and to ren- der, the results more enduring, has found its way into the -institutions throughout the continent and has become a recognized ancillary department in the dispensary as well as in the hospital. Its ac- tivities in the outpatient departments numerically exceed those in the hospitals. The growth of medical social service has been so rapid and spontaneous as to elude standardiza- tion. There exist differences in the fundamental conceptions of the functions of this new branch of hospital and dispensary organization and accord- ingly the methods of procedure and the technic differ materially. The existence of organized medical social service has been too short to provide for the training of workers on a scale commensurate with the impor- tance of the task and the tieeds of the service. Many of the hospitals give practical instruction in this branch of work to the pupils of the training schools. The first clearly defined and systematic courses of instruction were established by Simmons College in Boston and by the University of Indiana in connection with the Robert W. Long Hospital at Indianapolis. In Boston the course is given imder the auspices of the School for Social Workers main- tained by Simmons College and Harvard Univer- sity. It consists of class instruction and practice work in connection with the social service depart- ments of the Massachusetts General Hospital and the Boston Dispensary. In Indiana the instruction was originally given in the department of sociology but later was put in a department by itself. A course in medical social service is being offered at the University of California in conjunction with the department of social economics of the Univer- sity. The Chicago and Philadelphia Schools of Social Work, and the New York School of Social Work (formerly the School of Philanthropy) offer theoretical and practical instruction in medical social service, but all of it is still in the first stages of development, owing to the newness of the profes- sion and the lack of generally accepted standards. The Smith College Training School for Social Work has organized a course for medical social workers, following its successful war experiment in the training of social workers for psychiatric clinics. The course offered at Smith College con- sists of eight weeks of theoretical instruction, fol- lowed by a- period of nine months' practical train- ing at the hospitals with which arrangements have *This constitutes a part of the report on the Dispensary Situation in New York City by the Public Health Committee of the New York Academy of Medicine, of which Dr. Charles L. Dana is chair- man. Dr. James Alexander Miller is secretary, and E. H. Lewinski- Corwin, Ph. D., is executive secretary. ' One of the earliest experiments in hospital social service in New York was in connection with the Children's Department of the Post-Graduate Hospital, under the direction of Dr. H. D. Chapin. It was started in the spring of 1890. January 8, 1^21.] MEDICAL SOCIAL SERllCE. 1)3 been made for the purpose, and a concluding sum- mer session of class study. In the first eight weeks the students "are made acquainted with the applica- tion of the scientific method in sciences bearing upon social problems," and receive instruction in the etiology and the preventive aspect of certain diseases. The concluding period of advanced in- struction is designed to correlate the acquired field experience of the student with scientific research through class conferences, discussions and lectures. The department of nursing and health at Teachers' College, Columbia University, is likewise develop- ing a course of instruction for third, year students of approved training schools, as well as for graduate nurses. There "are probably other schools which ofifer similar instruction. The American Association of Hospital Social Workers, as well as local associations, present forums for the discussion of the various problems encountered in the discharge of the manifold duties devolving upon them. The Hospital Social Service Association of New York City holds stated meet- ings, publishes a quarterly and a bulletin and oft'ers a course of lectures to nurses interested in social work. Training of medical social service workers for certain types of cases, such as the tuberculous and mental, has been carried on by several organiza- tions. II. SCOPE AND FUNCTIONS. The bulletin of the department of social service of Indiana University descrebes medical social work as "a part of the wider public health movement and the present demand for efficiency, even in medicine." It goes on to say that a social service department fails or succeeds precisely in so far as it is able : 1. To procure for each individual patient whatever the medical institution needs for him, but should not itself pro- vide, in order to complete his care or cure. 2. To educate each patient and student with whom it comes in contact. He should understand the interrelations of vice, poverty, and disease; of physical, mental, and eco- nomic conditions. 3. To follow each patient until he is as thoroughly re- established as possible and to carry to his community, through the patient or otherwise, added knowledge of bad physical conditions — and a way in which to eliminate or prevent them — which increase man's burden and make for human misery. The formulation of the scope and functions of medical social service, as far as it has been at- tempted, emphasizes the importance of considering the environmental background of the patient in securing the best results from medical treatment. Davis and Warner ( 1 ) briefly define medical social service work as meaning "assistance to the physi- cians in the education of patients and the control of their environment." Miss Ida Cannon (2) de- scribes it as an ef¥ort "to understand and to treat the social complications of disease by establishing a close relationship between the medical care of patients in hospitals and dispensaries and those skilled in the profession of social work." For purposes of ascertaining the organization and methods employed in the medical social service departments in New York city, a survey was made of these departments with special reference to the dispensaries. An agent of the Public Health Com- mittee, herself a medical social worker, interviewed the person in charge of each department and also copied a number of records from the files of each department. Among the questions asked of the head of each social service dei)artment studied, was one relating to the function of the department as conceived by the institution. The following is a summary of the replies regarding the function of social service, 1, with reference to the clinic physicians, and, 2, With reference to the patients and the community. 1. As far as the relation of the social service department to the physicians was concemetl. "informing the doctors as to the social needs of the patients and of the assistance available throu'gh the social service department," was the definition given by six institutions. In four of the institutions the function was regarded as consisting of "reporting to the doctor the social conditions bearing on patients' illness." "Helping the doctor to complete treat- ment of patients" was the answer given by one of the chief workers. In three of the institutions the duty was conceived to be that of assisting doctors in carrying out treatment of patients; in three others, "interpreting doctors' instructions to pa- tients." Another formulated it as consisting of "assisting physicians in explaining advice to pa- tients" ; and still another as "assisting physicians in giving patients a new favorable start in the com- munity." 2. Regarding the responsibility of the social service department to the patient, fifteen institu- tions defined it as "establishing the patient or the family as an independent economic unit in the com- munity" ; seven as "education of the patient and family in hygiene," one, as affording "physical, mental and moral regeneration of the family" ; one as "assisting patient in regaining health" ; one as "educating the patient in the resources of the community, which 'can be used in solving his diffi- culties" ; one as "aiding the patient in readjustment after illn.ess" ; one as "advice and assistance to the family." One department dealing with mental cases only, defined its work as "education of the patient and the public in mental hygiene"; another specialized service, one dealing with children, limits its function "to the remedying of family difficulties to insure more efficient care of the child and prevent future illness." In the judgment of one depart- ment, "social .service work means special treatment when necessary" ; another limits its field of work to the "education of the patient as to the need of treatment"; two others, to "securing hospital treat- ment for the patients"; ajd still another to the "bringing of outside resources to co-operate with the hospital in the treatment of the patient." From this sivmmary it will be seen that the field of endeavor to which medical social service has ad- dressed itself is very broad and varied. In 1913 Miss Cannon wrote as being impressed "by the di- versities in the interpretations of the hospital social worker's function, and by the great need for more adequately trained workers" (3). A report of the committee on training made recently (June 5, 1919) at the annual meeting of the Ainerican Association of Hospital Social Workers likewise revealed the existing broadness of conception of the scope of 64 MEDICAL SOCIAL SERJICE. [Xew York Medical Journal. the work and the lack of standard methods of procedure. A study of the records of the several social service departments in the dispensaries of New York throws a great deal of light upon the methods pursued in social service work. As has heen stated above, six institutions recognize the education of the doctor to the social needs of the patient, as one of their functions. Assuming this to be one of the duties of the social service department, the two functions involved in carrying it out are : gaining the information and imparting it to the doctors. In the tuberculosis clinics and in the cardiac clinics the information as to the social facts is kept with the medical findings and is readily available to the physician. In all the other departments, with few exceptions, there are no systematic methods of con- veying to the physician the information about the social environment of the patient. The worker may • or may not remember to supply the doctor with the information ; at times he has to call for the desired data. The records of the social service department are not filed with the medical histories and there- fore do not become automatically available to the physician at the time when the patients present themselves for further attention. Three fourths of the institutions studied felt that their greatest obligation to the patient was to refit him for his place in the community. Yet among the patients under care in the various social service departments which came within the compass of our study, this was the evident problem in only a small percentage of cases. Seven head workers empha- sized the importance of educating the patients and families in hygiene ; among the cases studied about one third were accorded this service. The lack of precise formulation of the function of medical social service has resulted in the use of the department for all kinds of work belonging to other branches of the institutional organization, and has overburdened the social service depart- ments with work which might or should be handled through other agencies. As the medical social workers are usually nurses, they are frequently called upon to help the physicians in the clinics by taking temperatures, weight and cultures, to the detriment of their special work. As a broad propo- sition, it may be stated that the requests of the physicians and the managers determine the func- tions of the department to a very large extent. The analysis of the table of Functions Performed, found in another part of this report, bears out this statement more fijlly. III. THE PERSONNEL OF THE SOCIAL SERVICE DE- PARTMENTS AND THE EXTENT OF THEIR WORK IN THE DISPENSARIES. Practically all the institutions in New York whicli were known to maintain social service work were visited by the special agent of the Public Health Committee. Of the institutions studied, twenty- one had definitely organized departments, while in four the work was organized on a basis different from that of the ordinary social service department. The twenty-one institutions in which the social service could be studied for purposes of comparison are as follows : DISPENSARIES CONNECTED WITH GENER.AL HOSPIT.\LS. Bellevue St. Luke's Mount Sinai Beth Israel Post-Graduate Brooklyn Hospital Roosevelt Lincoln Long Island College New York Hospital French Presbyterian INDEPENDENT DISPENSARIES. Vanderbilt (College) New York Dispensary Cornell (College) Brooklyn City Dispensary University and Bellevue (College) DISPENSARIES CONNECTED WITH SPECIAL HOSPITALS. Woman's Hospital Ruptured and Crippled N. Y. Eye and Ear Infirm- Skin and Cancer ary Seventeen institutions have more than one worker. In many of the institutions there is no dififerentiation of function and the social service workers do the hospital as well as the dispensary work. Some of tfie institutions employ a consid- erable number of workers. In one hospital, for instance, there is a head worker with twenty-four assistants. One has a head worker and twelve assistants ; two have seven assistants each ; two have six assistants (in one of these, two of the assistants are graduate nurses assigned to hos- pital follow-up, and two are senior pupil nurses assisting in the home nursing, but directed by head workers) ; two have five assistants each; eight have two assistants each ; and four have one assistant each, making a total of 102 paid social workers. In addition, eight institutions have paid clerical helpers, two of them employed by one institution, which also has a bookkeeper, a messenger and a telephone operator in the social service department. Very few volunteers are used in connection with the social service work. Fifteen institutions do not use volunteers at all ; six use them only for clerical help ; and in only one institution are volunteers used in connection with the visiting of patients. The reason for this lies probably in the exactitude of the work and the importance of continuous service for efficiency. It is very seldom that volunteers can be counted upon to give intensive application to the work. In all the institutions the head workers com- plained of the shortage of capable assistants, and in seven institutions complaint was made about the inadequate office space allotted to the work. Fifty-seven of the assistants in social service work, or about sixty-two per cent., devote their time to the dispensaries. Of the seventeen chiefs of the social service departments, fourteen divide their time between the dispensaries and the hospitals, and three give all their time to the dispensaries. This large number of workers in dispensaries, as contrasted with the number doing hospital social work, shows the tendency away from the original limitation of social service to ward patients only, although in most of the institutions the main seat of the social service is still in the hospital. In only one of the general hospitals is the social service office located in the dispensary and doing most of its work for dispensary patients, aUhough it assists with indoor cases as well whenever they are re- ferred from the wards. In some institutions, how- ever, particularly the special hospitals, the hospital social service is regarded as of greater importance than the dispensary social service. January 8, 1921.] MEDICAL SOCIAL SERVICE. 65 IV. RESOURCES AND AUXILIARIES: AND ASSIGNMENT ^ OF STAFF AND ITS RESPONSIBILITIES. Funds for social- service are usually raised by women's auxiliaries which, either independently or jointly with the institutional authorities, exercise control over the social service. In seventeen insti- tutions out of the twenty-one included in this sur- vey, the funds were raised in this manner; only- four of these auxiliaries include any representation of the hospital board. In one hospital, the depart- ment was maintained by tlie New York School of Social Work, in another the Mental Hygiene Com- mittee of the State" Charities Aid Association main- tains social service for a certain type of patients ; and in two institutions a special fund, donated by private individuals, is put at the disposal, in one case of the superintendent of the hospital, and in the other of the director of nurses, who have sole authority over the social service departments. The total amount of money spent on social service work has not been ascertained, neither has the prevailing rate of salaries paid to the workers. In many insti- tutions the staff is insufficient to meet the needs (this was particularly so during the war) but only in one case, was a definite complaint made of lack of funds. Because of the independence of the funds for social service, the medical social service staff, un- like other paid workers in the hospitals, is account- able not to the superintendent of the institution, but either to the auxiliary only or to a composite body representing the auxiliary and the hospital authorities. In six instances their responsibility is entirely to the auxiliary composed of interested women who have no connection with the hospital management. In three instances the hospital or dispensary board is represented on the auxiliary. In one instance the supervising authority consists of the auxiliary, the superintendent of the hospital, the supervisor of nurses, and a representative of the board of managers, hi three instances the so- cial service is managed by the women's auxiliary and the superintendent; in one instance, the women's auxiliary and the supervisor of nurses ; in one in- stance, the women's auxiliary and the Association for Improving the Condition of the Poor ; and in four other instances, mentioned before, they are responsible to the Mental Hygiene Committee of the State Charities Aid Association, the School of Social Work, the superintendent of the hospital, and the director of nurses, respectively. With the exception of one instance where con- siderable friction was reported to exist between the social worker who was responsible to the auxiliary and the supervisor of nurses, the inquiry did not bring out the existence of any tension or adminis- trative difficulty due to the division of responsibility or the independence of the social service depart- ment from the rest of the hospital organization. The responsibility of the medical social service de- partment to a group of interested, nonprofessional women is of advantage in that it keeps the human elements of the problem fresh and vivid and brings to the aid of the work wider social and financial resources, but it is faulty from the viewpoint of administrative organization and is likely to retard the recognition of social service as an indispensable integral part of dispensary and hospital work, am- ple provision for which should be made in the gen- eral budget of each institution. V. THE TRAINING OF MEDICAL SOCIAL WORKERS AND THE REQUIREMENTS. In only three of the New York institutions studied are opportunities offered for the sy.stematic training of women for medical social service. One is the Post-Graduate Medical School and Hospital, where the social service department is a branch of the New York School of Social Work and where regular instruction is given : and the others are the Neurological Institute Dispensary and the Clinic for Mental Diseases at Cornell, where courses are given to such students of the Smith College Train- ing School for Social Work as specialize in mental hygiene. In no other institutions are any oppor- tunities for training provided, except that the pupil nurses of the respective training schools get a cer- tain amount of experience ifi medical social work under the guidance of the department. In four institutions this experience of pupil nurses does not exceed two weeks, one month, two months, and three months, respectively. In three institutions the opportunity is afforded to one nurse at a time — in one institution for one month, in the second for two months, and in the third for three months. In the institution where the three months' training is given it has been only for senior class nurses. In two institutions only probationers are instructed for a few weeks; in another, the pupil nurses are required to make visits with the medical social workers for a certain period of time. In the Pres- byterian Hospital the senior nurses spend four months with the Henry Street Settlement workers in addition to two months in the social service de- partment of the hospital. This constitutes the whole field of instruction available in the hospitals for either nurses or others desiring training in medical social service work. At every institution studied an effort was made to obtain from the chief of the social service de- partment a description of the essentials of educa- tion and other qualifications for a successful med- ical social service worker. A perusal of the an- swers shows that there is an insistence on the need of preliminary nursing education, and a lack of sufficient appreciation of a thorough grounding in social economy and social "case work." The prevailing idea among the medical social workers of New York is that nursing education is an essential prerequisite for the successful perform- ance of the work. It must, of course, be admitted that a great deal of the knowledge which a nurse possesses is of service in dealing with hospital cases and in connection with the visiting of certain types of cases, particularly where instruction to the pa- tient as to how to follow the doctor's advice in treatment is part of the problem. The fact of her being a nurse makes her message more authorita- tive. It is undoubtedly true, also, that a woman with initiative and imagination and a sympathetic interest in her work, possessing training in social 66 MEDICAL SOCIAL SERVICE. [New York Medical Journal. technulotiy, is fortified in performing her functions when she has had nursing education too. There are such women in the field of social work now, but it would "be inadvisable to limit the field of med- ical social service to nurses exclusively. Our study of the social service departments in New York has shown that the Post-Graduate Hospital, where the work is done by students of the School of Social Work imder the guidance of a director who has had no nursing training, compares very favorably with other institutions where none but nurse work- ers are employed. In the Massachusetts General Hospital, of the thirty-two workers only three are nurses. Miss Cannon, the chief of that service, herself a nurse, states that it is difficult to obtain women who, in addition to their nursing education, possess a thorough social training and are prepared to work as social workers, and not primarily as nurses. In Washington University Hospital (Barnes Hospital), at St. Louis, the University of Pennsylvania Hospital, at Philadelphia, and the General Hospital of Cincinnati, excellent social ser- vice work is carriec^ on under the guidance of women with no nursing education. Likewise, in the Robert W. Long Hospital at Indianapolis, which is part of the Medical School of the University of Indiana, the .social work is done entirely by students of the medical, nursing and sociological schools. The instruction and direction is given by women of no nursing experience. The character of the work done is of a high grade. Many of the students in the university utilize their experience in social ser- vice work as a basis for masters' and doctors' theses. It would therefore seem most inadvisable to exclude from the new profession by a rule of thumb the large numbers of women who, by editca- tion other than nursing, would be qualified to carry on the work satisfactorily. Furthermore, the training of nurses, as it has been carried on, and still is to a large extent, is not designed to nurture qualities of mind indispensable to successful social work of a high order. The nature of a nurse's work as ordinarily understood does not call for much initiative and independent judgment ; on the contrary, she must learn how to carry out instnictions. There are certain inhibi- tions which must become a part of her professional consciousness and behavior if she is to prove suc- cessful in her bedside work. Under the circumstances it was only from among the nurses who have had a broad prenursing edu- cation and who are possessed with a quick intelli- gence and a inind above the average that medical social service workers have been recruited in New York. It is due to these superior qualities, and not to their nursing education, that they have been able to render services of a high grade. The hospitals of New York, with the exception of two, have never tried to enlist the services of others than nurses for the work. As they are constituted at present, neither the training schools for nurses nor the schools for social case workers are of¥ering adequate prepara- tion for medical social workers. There is obviously a need of a new type of training which would qualify women for this new and growing profes- sion. By the nature of things it must be built on two foundation stones : one is a broad appreci^ion of the etiology of disease and an intelligent under- standing of certain medical procedures ; and the second is a knowledge of social conditions and the technology of family case work. VI. RECORD FORMS. As in the medical part of the study the character of the work was judged by the information gleaned from the records, so in the social service study an analysis of the records was made with a view of determining how the social service departments work, and what they accomplish. As in the case of the dispensary physicians, it is no doubt true that the social workers do more than their records indi- cate, but an objective study of the work must be made on the basis of what the worker considers worth recording for his or her guidance or for the permanent handling of the case. Before consider- ing the results of this analysis of case records, it will be well to consider the record forms now used. The employment of uniform record forms would be advantageous, even if it is .not necessary to record for every patient all of the information called for thereon, as such uniform records would facilitate the functioning of a central clearing bu- reau, and also would make possible studies aimed at the crystallization of social service function and procedure. At the present time there exists a great diversity in forms used. They differ in the amount of information called for, in the arrangement of items, as well as in the size of the forms themselves. The number of headings on the record^ ranged from sixty-five to twenty-seven. There are only nine headings which appear on all the forms from the fourteen institutions whose blanks have been analyzed. Those nine headings are : name of pa- tient, address, age of patient, addresses of friends and relatives, years in the United States, diagnosis, present occupation, marital status and earnings. With regard to the earnings, on three records there is no statement qualifying the income, as weekly or monthly. On twelve records the weekly income is inquired into, but in only five instances was it made clear whether it was the income of the last week or of an average week. On some records pro- vision is made for the ascertainment of both the "present wage per week" and "the normal wage per week." Some of the records call for just the wages, o'thers for incomes from all sources. It goes without saying that a uniform and precise procedure with regard to so iinportant an item as the financial resources of the family is essential. On all of the records except one, information is asked concern- ing the church affiliation of the patient-. Without going into detailed computations on how many of the blanks the several items of information are found, it may be said that the records diflfer considerably from each other, but as a rule ample provision is made for obtaining essential facts. The facts sought can be broadly divided under six heads: 1. Information needed for the identification of the patient, which includes data concerning the patient's name, address, age, sex, nationality, time in the United States, conjugal status, etc. 2. Med- January 8, 1921.] MEDICAL SOCIAL SERVICE. 67 ical history, i. e., past and present histor\-, the diag- nosis, treatment and complications of condition. 3. The training and work of the patient, which covers education, special fitness, past and present occupa- tion and the nature of work. 4. Home and family — This calls for information concerning the size of the family, the number of dependents, -number of rooms occupied, ventilation, and other sanitary fea- tures of the dwelling. 5. The financial .status — by which is meant information concerning the wages and other sources of income, also data bearing on the budget of the family, particularly such items as rent, insurance, and other definite ascertainable expenses. 6. The social service problem and what has been done for the patient. The information concerning all these points is inquired into by the several institutions with a vary- ing degree of fullne-ss. The greatest similarity of questions pertains to the identification information. The items concerning the medical history show a minor degree of likeness. Every record, however, has space for diagnosis. On some of the blanks there is an entry for previous treatment or for previous places of treatment, and on two, for pre- vious illness. Likewise on only two of the cards is space provided for present medical treatment and on three for complications. It would seem that the records call for too little information concerning the physical and mental condition of the patient, the mode of treatment prescribed and progress made under treatment. With regard to the training and work of the patients, the present or last occupation is invariably inquired into. Only one of the cards suggests an inquiry into the process of work and only three ask about the industry in which the patient has been employed. In five institutions the question is asked whether the employment is seasonal or steady. The question of unemployment is raised on nine of the record forms. In only one instance are the hours of work inquired into. Something regarding the education of the patient is required to be recorded in three institutions and in two his vocation and special training. Here, again, one might criticize the forms in that they do not provide for an ade- quate elicitation of information concerning the in- dustrial hazards of occupations and evidently do not lay particular stress upon the relation between disease and thp work and habits of patients. With respect to the home and family conditions, the information required is full and more or less uniform. Here again little importance is evidently attached to the obtaining of facts concerning the condition of health of members of the family other than the patient. Such information would be of importance from the point of view of making plans for the family as well as from the standpoint of disease prevention. With reference to the financial conditions of the patients, the questions about the income have been discussed above. On the whole, the schedules on that score are satisfactory, although in only few instances are inquiries made into the family budgets, except as to expenses for rent. As to the social service problem, in five instances the arrangement of the record calls for a definite statement of the social diagnosis or tlie immediate need or the apijarent underlying prol)lcni. In all other instances no statement of the [jroblem is at-' tempted. The same five record blanks, with per- haps one exception, call for rather minute informa- tion concerning the social worker's efi'ort in the case and the final disposition of it. The other cards vary in detail with regard to these points : some provide for the discussion of items of relief and other services performed. The records can be im- proved in this respect also. On the whole it may be said that the social ser- vice record forms, as they are, call for a great deal of relevant information. In most instances the data secured are probably sufficient to permit a proper planning of action. What most of the records need very badly is a topical arrangement of information under several general headings and the segregation of data in such a way that the details of the investi- gation would be separated from the main facts about the physical condition of the patient and his economic and social difficulties. Above all there is a need of a similarity of recording of the facts and also of assigning precise meanings to the terms used. VIl. STUDY OF THE CONTENT OF SOCIAL SERVICE RECORDS. An analysis was made of 675 records selected at random from the files of the institutions studied. Of the records examined 301, or 44.5 per cent., were children's cases; 121 concerned men, and the remaining 248, women. These records gave detailed information of the types of cases which receive the attention of the social service departments and of the methods of work employed, as well as the re- sults achieved. Tabulation of the records shows that on 88 .per cent, of them medical findings are indicated. It is admittedly of prime importance that the medical condition of the patient should be' stated in every instance of medical social service work. Likewise, in making plans for patients it is of importance to know and record what medical treatment has been indicated, and if no medical treatment is necessary, this fact should be recorded ; and yet only 59.3 per cent, of the records contain any reference to medical treatment. In 27.5 per cent of cases the family history of the patients is recorded and in only 20.3 per cent, of the cases is the patient's medical history given. Of the 675 patients whose records were ob- tained, 77.5 per cent, were visited in their homes. In the majority of institutions over 90 per cent, of the patients were visited. In some institutions all cases referred to the social service department are visited. Some, however, show a relatively small percentage of home visits- and this accounts for the average of only 77.5 per cent, of the cases visited. Among those which are considerably be- low the average in visiting are some of the best general out. patient departments, an excellent clinic for special cases and two university clinics. Al- though the total number of home visits recorded equals 77.5 per cent, of the cases, the general de- scription of the home conditions is given on only 50.7 per cent, of the records, while 68.6 per cent. 68 MEDICAL SOCIAL SERF ICE. [New York Medical Journal. of the records indicate the number of rooms occu- pied by the families visited. The sources of income of the family are recorded in 71 per cent, of the total number of cases, and the family expenses are given in 69 per cent, of the cases. In the majority of instances, however, only several items of family budget are ascertained, chiefly rent. The present occupation of the patients is indi- cated in 61.5 per cent, of the cases, and the past occupation in 55.5 per cent. This poor showing with regard to a vital point of information cannot be explained by the fact that 44.5 per cent, of the cases were children and 36.7 per cent, women, be- cause in ever>- instance of a child the occupation was regarded as stated ; likewise, in cases of women, when the term housekeeper was given the occupa- tion was considered to have been recorded. In addition to the visits to the homes of the pa- tients, the social workers called on other persons or agencies which might be interested in the case, such as relief agencies, churches, employers, rela- tives, etc., and the records show that in 17.2 per cent, of the cases such additional visits were made by the workers. Besides these visits, other agencies were communicated with by letter or telephone, so that in all, cooperation was souglit in about 39 per cent, of the cases. It was on the basis of the medical data as to con- dition and treatment and on the information elicited by visits to and talks with patients, families and others interested that the social service problems were ascertained and plans laid to meet these prob- lems. In 96.5 per cent, of the cases the social ser- vice problem is indicated on the records", and in 93.6 per cent, of the cases the solution of the prob- lem is formulated. Of the 675 cases- selected at randqm only 20.6 per cent, were recorded as closed, and of these only three fourths bore the date of the closing. Some of the open cases were of long standing and no active work was being done with them. The study of the records indicates that nov/here has an at- tempt been made to ascertain the end results of the work and therefore it is impossible to judge in many instances what have been the achievements of the social departments. An effort was made to determine the causes for closing cases or the reason for keeping them open. In ninety cases, or 13.3 per cent, of the total, we could not determine whether the cases were open or closed. Of the 20.6 per cent, closed, in 9.8 per cent, the object had been accomplished. A small percentage was closed for each of the following- reasons : other organizations were interested ; the patient died or was lost in moving to another dis- trict or giving a wrong address ; some were referred to other doctors or institutions better fitted to treat the patients ; and in ten cases investigation showed no need for care. Three of the five cases classed as other reasons are significant in that they were closed because of a shortage of workers. The cases were from a teaching institution where the policy is, apparently, that no more work should be at- tempted than can be properly carried out. Among the 446 cases known to be pending, no reason for keeping the cases open could be ascer- tained for eighty-four patients; 322 needed further medical care or home instruction ; twenty-three cases needed further financial aid ; several of these cases were held open to repay a loan made for apparatus or special treatment. Opposition of the family made it necessary to keep three cases open, while among the cases closed, one was found where the reason for closing was uncooperative patient. According to the records only 40.5 per cent, of the cases were registered with the social service exchange of the Charity Organization Society. Some institutions make a large use of this agency, recording every case. One institution obtains infor- mation from the social service exchange, but regis- ters no cases with them, the reason being that the relation of the patient to the medical institution should be confidential and no names of patients should be divulged to an outside agency. VIII. TYPES OF SOCIAL SERVICE ACTIVITIES. The work of the several social service depart- ments has been summarized under nine heads, on the basis of the information given as to what con- stituted the problem in each of the 675 cases ana- lyzed. The main problems thus ascertained were found to be: 1. Home nursing . and instruction. 2. Followup work with the patients to secure their return to the clinic for further treatment and ex- amination. 3. Securing employments suitable to their conditions. 4. Arranging for family readjust- ment so as to enable the patient to go either to a convalescent home or to a sanatorium, and to take care of the family during the absence of the father or mother. 5 : Convalescent care of the patients: 6. Institutional care. 7. Additional clinic attention either at the same clinic or at some other clinic where the condition of the patient might be treated to better advantage because of the ampler facilities. 8. Securing financial aid for the patient and the family. 9. Investigating the various bearings of environment with reference to the patient's con- dition. The following is a summary of the various types of social service work done in the twenty-one in- stitutions included in the present survey: Xiimbcr Percent Home Nursing and Instruction.... 221 32.9 Follow up 47 6.9 Employment 17 2.5 Family Readjustment '25 3.7 Convalescent Care 77 11.7 Institutional Care 117 17.3 Additional Clinic Care 45 6.6 Financial Aid 94 13.9 Investigation as to Problem 3(F 4.5 Total 675 100 - Two cases, problem not stated. According to this classification the largest num- ber of cases, or 32.7 per cent., were in the group of home nursing and instruction. In other words, almost one third of the cases, in the judgment of the social service workers, required sanitary super- vision in the home, instruction in hygiene and diet, home nursing, or direction as to the carrying out of treatment. In this respect four institutions, of which three are large general out patient depart- January 8, 1921.] LONDON LETTER. 69 ments of hospitals and one«Q detached general dis- pensary, show the largest percentages. 13.8 per cent, of the patients were financially harassed and the social service departments felt that their func- tion was to step in and obtain for the families the needed aid; three institutions, one a large general out patient department, one a university clinic, and the third an institution for the treatment of special conditions, have the largest relative number of financial aid cases. Providing institutional care was another of the most frequent functions of the social service de- partments; 17.3 per cent, of the cases in the study received this kind of attention from the social ser- vice. Another large group, constituting 11.7 per cent, of the total number, received convalescent care. In 6.9 per cent, of the cases the function of the social service department was to follow up the patients and bring them back to the clinics. This was found being done at only seven institutions, and chiefly in connection with cases 'of tuberculosis and poliomyelitis. The finding of employment and making family readjustments are evidently not among the frequent duties which fall upon the social service depart- ments as they function at the present time. It is surprising that in only 2.5 per cent, of the cases the chief problem was the need of arranging a change of occupation for the patients, and likewise in only 3.7 per cent, of the cases the chief problem was the need for family readjustment due to the illness of either the breadwinner or the mother. REFERENCES. 1. Davis and Warner: Dispensaries, New York, 1918, p. 101. 2. Cannon, Ida: Social Work in Hospitals. New York, 1913, p. 1. 3. Loc cit., p. vii. (To be concluded.) ■ LONDON LETTER. (From our own , correspondent.) Medical Men Organising in Great Britain — Treatment of Eye Diseases in Great Britain — The Coal Smoke Curse and Its Conquest in America — Care of the Tuberculous — Institute of Physics— Epidemic Diseases in London. London, December jgjo. It has long been evident that unless medical men organized to protect their own interests they would be unable to carry any weight. Politically the medical profession is practically impotent and as the Ministry of Health is largely a political body, and as the bulk of the inhabitants of Great Britain can call upon the services of medical men under the insurance scheme, if doctors are not strong enough to resist they will be almost at the beck and call of their patients. It must be borne in mind that those who can claim medical treatment under the insurance act are not especially favorable to the medical profession, in fact, a considerable propor- tion is frankly antagonistic. In the event of a clash between medical men and their clients, it might go badly with the doctors. The Ministry of Health after all, is a department of the Government, and its actions are likely to be swayed by political motives. Those who can wield the power will have the best chance of getting their own way and per contra. The medical men have not the power at the present time and are therefore likely to be imposed upon. it is encouraging to learn that medico])olitical unions are being formed. The inaugural dinner of the North London branch of this union was held on December 2d, last. Among those present was Dr. E. S. S^ancomb, president of the union, who spoke in part as follows : He said the object of the union was twofold, viz., to do their duty to the communit\' and to protect themselves against too much red tape and interference. It was not their desire to oppose progress. In the past few years they had seen pro- cessions of the men who fought in the air and on the sea and under the sea and on the land, but they had not seen a procession of the medical men who were engaged at the front abroad, and at the home front, looking after our sailors and soldiers, their women and children, and the community generally. If it had not been for medical science we should have been beaten to a frazzle. If the medical men could organize during the war for the good of the com- munity, they could organize with the same object now that we had peace, at least comparative peace. At the present time the medical officers of many important boroughs were paid considerably less than other officials, such as \he gentlemen who looked after the trains and the electricity. The health of the community was the real wealth of the com- munity. Their object, in brief, was not to strike as the term v/as generally understood, but, if neces- sary, to strike against Government parsimonv and red tape and interference. The doctors undoubtedly were in a position to understand the needs of the community better than many other gentlemen who found their way to the House of Commons, and the doctors should be better represented there. In the organization of the Ministry of Health and its work the medical profession as a whole had been ignored. That was because medical ITICII lis. d hither- to failed to combine in any way. Dr. Nathan Raw said he was certain if other branches of the union were fomied in the same vigorous way in which the North London branch had been brought into existence the doctors of the country would soon make their voices heard, not only in London, but throughout the country. In- deed, if the medical profession could unite on one policy they could practically rule the country. The doctors in the. House of Commons at the moment were so few that they carried less weight than many sections of the community with much less responsibility. He therefore hoped to -see doctors combining all over the country, and thinking out great policies for the good of the country and for the protection of their dignity and privileges. Little was known concerning the surgery of the eye in Great Britain until the expedition into Egypt under Sir Ralph Abercrombie took place following the advance of the French into the land of the pyramids led by Napoleon Bonaparte. The British troops became the victims of contagious ophthalmia, then and now widely prevalent in that country, and 70 LONDON LETTER. [New York Medical Journal. brouglit back that scourge into (ireat Britain. In- capacitated from further fulfiUing their military duties, the disease was spread by these men through- out the length and breadth of the land. In the Daily Telegraph, December 4, 1920, is given an interesting account of the beginnings and development of scientific eye treatment in this country. As said before, little was known of eye treatment in the years about 1802. It was largely an open field for quacks and impostors. *A young surgeon, John Cunningham Saunders by name, was one of the first to realize die need for a closer study of the eye and its diseases, and he proposed the foundation of the ]\Ioorfields Eye Hospital, of which he was the first surgeon and which has established its fame as an institution of its kind second to none. Although no longer in Moor- fields, having been removed to more spacious and adequate premises, and although officially it is the Royal London Ophthalmic Hospital, it is known in all parts of the English speaking world as Moor- fields. Postgraduate students not only come from Great Britain, but surgeons from America, Canada, and from practically all quarters of the globe, to this London eye hospital. A touching tale is told of its connection with America in its early days. Dr. Edward Reynolds, from Boston, Mass., ar- rived in the year 1816 to pursue his studies at Moorfields. On his return to America he found his father blind from cataract in both eyes. Forti- fied by the skill and experience he had gained in London, he operated and restored sight. It is said that the operation for cataract was invented and first performed in IMoorfields. The object of the article referred to was to call attention to the desperate plight in which this institution finds itself from the financial viewpoint. For 115 years the hospital has been doing its healing work, saving the sight of the young, restoring the sight of the aged, alleviating pain, making good the eye injured by accident, sending citizens from its doors well capable of earning their living who, but for its ministrations, might have become blind dependents of others. But as is the case with all other institutions here for the care, relief and treatment of the sick and injured, Moorfields is so hampered in its work through lack of funds that unless money is quickly forthcoming its capacity for good will be wrecked. This year investments of the face value of £8,000, given or acquired when four per cent, was good return for money, will have to be sold for what they will fetch. Maintenance costs have doubled. Salaries, which for nine months in 1917, after three years of war, were £3,013 (15,065), are now
£5,701 ($28,505). The burden of rates, £820 ($4,100) in 1914, is now £1,280 ($6,400), and will be higher. It may be mentioned that no one is ever kept out because he or she cannot pay, but in- patients are now asked to pay what small sums they can afiford. As for outpatients, contributions are still voluntary. An appeal is now being issued for £100,000 ($500,000), to which it is hoped there
will be response in America, India, and Canada, as
well as in Great Britain. While, of course, all
British hospitals are in a desperate condition finan-

cially, and while equall^', of course, all are deserving,
the big London eye hospital is perhaps more deserv-
ing than many. Blindness is one of the most ter-
rible afflictions to which the human race is subject,
and is frequently easily prevented. For example,
ophthalmia neonatorum, if not treated in time,
inevitably leads to blindness. On the other hand,
if treated early it is generally amenable to proper
treatment. In the case of threatened loss of sight,
the old adage, "prevention is better than cure," is
more emphatically true than in most diseases, and
preventive treatment is assuredly better in every
respect than caring for those who have become
irretrievably blind. Therefore, Moorfields should
not be allowed to lose its capacity for good. Such
an event would be a national disaster.

The financial state of the hospitals is a question
which is now arousing concern in all circles, and
is a problem which must be met, and met soon.
The voluntary system, if it has not broken down
entirely, is inadequate to cope with existing con-
ditions. However, steps are being taken to deal
with the situation, and when matters in this direc-
tion are more matured, they will be discussed in
succeeding letters. The hospital problem is the one
of the hour, so far as the health of the people and
the medical profession are concerned.

* * *

On more than one occasion the evils of coal
smoke in the cities of Great Britain in general and
of London in particular, have been discussed in
these letters, and it has been pointed out that its
continuance is mainly due to lack of obvious
methods of prevention. That it is unhygienic can-
not be denied, and that it is decidedly unpleasant
is just as patent, but the British public appears to
endure the infliction with equanimity if not with
indifference. It is an evil to which all are inured,
one perhaps almost hallowed by long use. How-
ever, there are a few in this country who now and
then lift up their voices in protest against such an
unhealthful custom, and there are even signs that
some, at least, of city, dwellers are beginning to
rouse themselves from their lethargic attitude.
Among these would-be reformers is Dr. C. W.
Saleeby, who, in season and out of season, has
never hesitated to denounce the practice of allow-
ing the air to be laden with particles of coal dust,
to the hurt of those who suffer from bronchial or
other respiratory diseases, and to the discomfort
of all. Dr. Saleeby delivers himself of his views
in the correspondence columns of the Medical Press
and Circular, November 24, 1920. As he has only
recently returned from a second visit to America,
he is able to compare the conditions as regards the
smoke nuisance in the cities of that country with
those which prevail in London. The comparison is
not flattering to the hygienic methods of British
sanitarians. He draws attention to the fact that
under the New York regulations no one burns soft
coal, but that while in the British health act black
smoke is forbidden, the law is so easily evaded that
it is virtually a dead letter. He further makes tlie
pungent remark that if the industrial chimney can
be rendered innocent in Pittsburgh, as according
to him it has been rendered innocent, it need be

Januar, 8, 1921.]

LONDON LETTER.

71

noxious nowhere. He goes on to show that the
domestic chimney sins not at all in America, be-
cause the women of the United States and Canada
live in houses where just a little science and just
a little sense have been invoked.

A Departmental Committee on Air Pollution by
Smoke and Other Noxious Vapors, was appointed
by the Ministry of Health early in this year, and
has pubHshed an Interim Report, in which Dr.
Saleeby declares every one of the contentions laid
before it was accepted. The committee recommends
that no new house should receive official approval
unless it be designed so as to be smokeless. How-
ever, despite this recommendation, the public seems
as indifferent as ever to the coal smoke evil. Dr.
Saleeby, therefore, writes in the hope that the small
proportion of British citizens who have had training
in the elementary laws of life may concern them-
selves in a sanitary reform which may make the
air and light supply of British cities comparable
in quality with their water supply, in which matter
Britain led the world as far as she now lags behind
in those others no less important.

* * *

It has been widely announced in this country that
sanatorium treatment of the tuberculous is a failure.
The Committee of the Sanatorium Benefit of the
L6ndon Insurance have had large experience of
this form of treatment, having been responsible
from 1912 to 1920 for the provision of sanatorium
treatment for more than twenty thousand tuber-
culous persons. Dr. Henry Lesser, chairman of
the Insurance Committee of the County of Lon-
don, contributed recently a letter to the public press
in which he points out the committee's medical
adviser, Dr. Noel Bardswell, has submitted reports
on the treatment furnished by the committee and
the lessons to be derived therefrom. Above and
beyond all question there emerges the simple fact
that sanatorium benefit is a failure. Of the patients
whose treatrnent was commenced by the committee
during the year 1914, over seventy per cent, were
dead before the end of 1918. Dr. Lesser contends
that obviously to continue the present arrangements
for sanatorium treatment would be vmeconomic and
inexcusably wasteful. Prominent men who have
jgiven their lives to the study of this terrible problem
in its social, economic, and medical aspects, are
impressed with the urgent need for certain improve-
ments, among which are : Encouragement of experi-
mental colonies and settlements ; experiments on the
lines of local work centres ; the subsidy of after-
care work to be limited to one or more selected
boroughs.

It was understood that the Ministry of Health was
introducing a Tuberculosis Bill, clauses of which
provided for the provision of village settlements or
colonies for the tuberculous and the care and assist-
ance of tuberculous persons and their families. It is
now proposed to omit these clauses, mainly on the
grounds of economy. It is argued, however, that
economy of this kind is quite false economy.
Sanatorium treatment has been given a lengthy
trial, and has proved, on the whole, a complete
failure. On the other hand, the colony and village
settlement system seems to be successful.

The best example in Great Britain of this system
is at Papworth, near Cambridge. The writer a
short time ago visited this colony and inspected
it closely. He was greatly impressed with all he
saw, and intends to send an account of the Pap-
worth Sanatorium, colony and village settlement,
to the New York Medical Journal. The Min-
ister of Health is aware that the sanatorium by
itself is of little or no use, and he also knows that
the colony and village settlement system has, on a
comparatively small scale, it is true, answered well.
It is a financial question, but as said before it does
not seem to be sound economy to cheesepare when
dealing with tuberculosis. The tuberculous person
working with his fellows at a certain stage of the
disease is a menace. For the sake of the community
and for his own sake it is best that he should be
segregated, and what more effective mode of segre-
gation can be devised than by placing him or her
in colonies, industrial or agricultural, and village
settlements, where he can render himself self-
supporting or partly so, and where he will be no
source of danger to his fellowmen, which is, after
all, of the first importance. .

* * *

It was announced recently that the Institute of
Physics has been incorporated and has commenced
to carry out its work. The object of this institute
is, on the one hand, to secure the recognition of the
professional status of the physicist, and, on the
other hand, to coordinate the work of all the societies
interested in physical science or its applications.
Five of these societies are already participating,
namely, the Physical Society of London, the Optical
Society, the Faraday Society, the Royal Micro-
scopical Society, and the Rontgen Society. Two
hundred fellows are included in the first list of
names. Sir J. J. Thompson, the retiring president
of the Royal Society, has accepted the invitation
of the board to become the first and at present the
only Honorary Fellow. Sir Richard Glazebrook,
F. R. S., is the first president of the institute.
Physics is beginning to take its rightful place in.
the education of the medical student. It is recog-
nized that a knowledge of physics is essential in
a thorough medical education, and already some of
the British medical schools have established chairs
of physics.

* * *

In answer to a question asked in the House of
Commons recently with respect to the prevalence of
diphtheria, scarlet fever, and influenza in London,
Dr. Addison, the Minister of Health, replied that
scarlet fever and diphtheria had been exceptionally
prevalent in London during this autumn, but both
diseases were of an exceedingly mild type, and the
death rate in each case was far below that experi-
enced in previous epidemics. There was no evi-
dence of the existence of epidemic influenza in
England at the present time. The origin of these
waves of zymotic disease was obscure. Similar
though more fatal outbreaks occurred in 1892 and
1893. He was glad to say that existing machinery
and the available hospital accommodation had
proved equal to the task of coping with the present
outbreaks.

Editorial Notes and Comments

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NEW YORK, SATURDAY, JANUARY 8, 1921.

THE EVOLUTION AND PROGNOSIS OF
ABDOMINAL AORTITIS.

The evolution of abdominal aortitis is essentially
variable, as everything depends upon concomitant
lesions and the etiology of the process. From the
viewpoint of the progress of the affection the aortitis
may be distinctly localized or descending. The in-
vasion is different according to whether the case is
one of acute aortitis or a chronic process from the
onset or following an acute lesion.

Acute aortitis sometimes develops very rapidly,
the affection reaching its height in a few days, but
when it assumes the chronic type its onset varies in
character and is generally slow in developing. In
the majority of cases the process is localized, re-
maining limited to the portion of the vessel extend-
ing from the subdiaphragmatic part to the bifur-
cation of the iliacs. The process is often localized
but extensive, as is evident from many cases where
both the aorta and the iliacs were sensitive and pain-
ful, while in an instance recorded by Teissier a dou-
ble murmur heard over the umljilicus could also be
heard over both iliacs, which were painful but
ended there. As a third possible evolution abdomi-
nal aortitis should be mentioned following a slowly
descending progress, as in the case of Roque and
Corneloup, where the process, at first seated in the
ascending portion of the aorta, extended progres-
sively, at first being thoracic and then abdominal.

The evolution of the disease depends on the con-
comitant lesions and is essentially related to them.
Usually the process is of moderate intensity without
any alarming symptoms, but in other cases the symp-

toms presented are so acute that the process must be
regarded as a serious type of the affection. The
disease may undergo an evolution in distinct recur-
rences, although this is not common. The chronic
forms may succeed the acute type, but generally
these cases, when they first come under observation,
have been going on for months or even years, and
it is only after this lapse of time that the symptoms
become manifest. The evolution of these chronic
cases is occasionally effected by painful paroxysms
occurring at distinctly fixed intervals ; or the evolu-
tion may be slow with persistent pain, and although
this is ameliorated by treatment it does not entirely
subside.

The prognosis of the acute cases quoad vitam is
usually good. In the chronic cases there are dis-
turbances resulting from atheroma, in which case
the prognosis is dependent upon the latter lesion.
Atheroma, "the rust of life," as Potain called it,
prepared the way for spontaneous rupture of the
vessel, and this accident occasionally takes plaoe.
Consequently the prognosis in cases of chronic ab-
dominal aortitis should be guarded. A bad prog-
nosis should naturally be made when the aortitis is
complicated by either gangrene or hemorrhagiparous
lesions, an infarctus often being the cause of death,
and when the abdominal aortitis is complicated by
an aortitis in the upper portion of the vessel, we
must rely upon the heart for the prognosis.

NEW PROVISION FOR THE HOSPITAL
CARE OF THE SICK IN MIND IN* CANADA.

By means of juvenile courts, observation homes,
big brother and big sister movements, psychopathic
hospitals, the whole Dominion of Canada is taking
progressive steps toward ameliorating conditions as
they are to be found among mental and nervous
abnormal cases, other than those congenital cases or
those suffering since birth, and the certified insane.
Dr. Helen Boyle, the distinguished authority on
mental disease, who has recently lectured in different
sections of the Dominion, has reawakened the con-
science of legislators and others to the crying needs
of the problem as to how to care for Canada's un-
fortunates.

Some years ago, perhaps five or six, the Govern-
ment of Ontario appointed Mr. Justice Hodgins, of
Toronto, to make a report on the whole situation of
the feeble minded as it affected that province. His
report has now been before the present Government
more than a year, with the result that it appears to
have been pigeonholed. Some aver that the action

January 8, 1921.]

EDITORIAL ARTICLES.

73

of the Ontario authorities, or, rather, the inaction,
is greatly hindering the handling of the problem of
the feebleminded all over the Dominion. Less than
three years ago the Canadian National Committee
for Mental Hygiene" was called into being ; and the
most recent piece of work done by that committee
was the making, at request, of a mental hygienic
survey of the province of New Brunswick. It in-
cluded an investigation of some eighteen institutions
caring for insane, feebleminded, delinquents, depen-
dents, and unmarried mothers, together with a
mental examination of five thousand children attend-
ing eleven representative public schools in that
province. Of course, the survey was made with the
view of determining the nature and extent of the
problem there, what facilities were available for deal-
ing with the situation, and the needs for the future.
New Brunswick is one of seven provinces that have
called upon the Canadian Hygienic Committee for
assistance along these selfsame lines; and in many
instances the advice of the committee has been ac-
cepted, and now two provinces are spending one and
a half million dollars on mental hygiene activities.
Thus, while more adequate facilities are being pro-
vided, more scientific treatment has also been made
available ; more preventive measures have been
adopted and more ctistodial care supplied.

In three years the Canadian committee has in-
spected, outside of Toronto, thirty-six provincial and
county hospitals for the insane, twenty jails, seven-
teen industrial homes, and eleven homes for de-
pendents. The inspection involves a complete men-
tal examination of all inmates with the making of all
necessary tests. There have also been examined
2,405 children attending private schools, and 5,500
immigrants and 350 unmarried mothers. The find-
ings have been presented to the various govern-
ments concerned with resulting needed changes.
One of the particular presentments has been that
concerning immigration ; and the assurance may now
be given that the Federal Department of Public
Health is handling that aspect of the problem with
intelligence and exactitude. For the first time in
Canadian history physicians with a knowledge of
psychiatry are inspecting immigrants at ports of
entry, and within the last few months have rejected
many with sufficient evidence of unsound mind to
warrant their deportation.

It is interesting to note that several psychopathic
hospitals are to be erected in various parts of
Canada; and only recently the Ontario Government
has acquired the Speedwell Military Hospital at
Guelph for the purpose of additional accommoda-
tion for Ontario's insane. In the many new institu-
tions shortly to be called into active service, cases

of mental disease will be accepted as easily as are
admitted into the wards of a general hospital those
with physical derangements. They will be observed
and treated for a limited period ; and if the experi-
ence of the Winnipeg Psychopathic Hospital can be
taken as a criterion, more than eighty per cent, can
ultimately be returned to their own homes. Such
practice will obviate the necessity of sending many
to hospitals for the insane, with distress to friends
and relatives alike, as well as obviating the horrible
possibility of being confined in common jails with
the criminal classes — a practice which might well be
styled an anathema of any civilization. During the
last three years the Canadian Mental Hygienic Com-
mittee has carried on its work on gifts of some
$90,000, and its requirements for the next three years are estimated at$135,000. It is believed that
Canada, with earnest efifort, will soon have sur-
mounted the problem of the mental defective, the
dangers involved in neglect of this matter, and a
saner, wiser policy of broad and universal adapta-
tion to the needs of her unfortunates. -

PHYSICIAN AUTHORS: DR. GEORGE
CRABBE.

George Crabbe is practically unknown to readers
of the present day, and literary reviewers have a
hard time of it trying to explain why this is so. Why
has a poet and realist of Crabbe's acknowledged
skill gone so completely out of vogue — especially
one who was praised with such unwonted enthusiasm
as was Crabbe? "Though Nature's sternest painter,
yet the best," said Byron. "His poems are the most
touching in our language," said Cardinal Newman.
"One of the masters and renovators of poetry," was
Taine's verdict. "The Hogarth of modern bards,"
said Dibdin. "Crabbe's poems will last from their
combined merit as poetry and truth," said Words-
worth. Edward Fitzgerald, of Omar fame, was
even. more ardent than these. Praise of Crabbe is
scattered profusely throughout his many volumes of
correspondence. Tennyson, Dickens, Macaulay,
Jane Austen, Leslie Stephen — in fact, there is
scarcely an English man of letters of the last hun-
dred years who hasn't spoken his word of praise
for Crabbe. He has been described as "the truest
realist in the English language" and a "fine and
genuine poet with a clear vision of life." Every-
body who has read him puts him among the classics,
but, alas ! it is hard to find anybody who has read
him.

Three outstanding reasons for Crabbe's lack of
popularity, in face of all this encomium, have been
advanced. First, he wrote in verse when he should

74

EDITORIAL ARTICLES.

[New York
Medical Journal.

have written novels. He could have been another
Thomas Hardy. The author of Tcss of the D'Ur-
bcrvilles gives Crabbe the credit of having been the
most potent influence that affected his work.
Crabbe's forte was the novel, had he but known it.
His poems are novels in verse — good stories that
leave a vivid impression on the mind. "Crabbe's
genius was unfortunate in finding no other vendible
vehicle for his thought than verse," said Andrew
Lang, "for his natural bent was the modern
realistic novel on the squalor, sufferings and sins
of the neglected rural poor." Lang touches upon
the second principal reason for Crabbe's oblivion.
His genius was "too grim and stern" ; his gift,
though perfect, was too sinister. And yet, his
admirers will tell you there is buoyant humor and
gaiety of heart in Crabbe's work. Sir Walter Scott
on his deathbed said : "Read me some amusing
thing; read me a bit of Crabbe," and chuckled and
said "Splendid !" as it was being read. The last
big reason for Crabbe's eclipse is that his style, as
Taine poinj^ out, was too classical. His general
literary form and manner hurt his popularity. Pope
was his model. All his tales are written in the
rhymed couplet of the Pope school. And so he was
nicknamed "a Pope in worsted stockings." It has
been said, also, that he diverges too much from the
trend of modern thought. Somehow these explana-
tions fail to explain, but the fact remains that
Crabbe is little read. He is not, of course, wholly
neglected. He has his little coterie of staunch
admirers. : Oliver Elton optimistically says that
"his day may ripen again." The chance of this
seems remote. He is perhaps not destined to be
popular again, but his place in English literature is
secure, and for those who like poetical pictures of
the grim and depressing side of life he can be safely
recommended.

Crabbe was born on Christmas eve, 1754, in
Aldeburgh, on the Suffolk coast, and died on Feb-
ruary 3, 1832. His early life was one of bitter
poverty. After a few years of schooling he began
helping his father as a worker on the docks and in
warehouses at Aldeburgh. At fourteen he- was ap-
prenticed to an apothecary and at fifteen was
api)renticcd to a surgeon. Later on he practised
medicine and surgery in a humble way in Aldeburgh
and Ipswich, but his success was small and his
penury extreme. Again he became a warehouse
laborer, but continued to study medicine and in 1777
went to London, where he spent nine months work-
ing in hospitals. In a letter to his sweetheart,
Sarah Elmy, whom he always addressed as "Dearest
Mira," he mentioned that he had to sell his surgical
instruments to pay his bills. It is related that while

in London he had a narrow escape from being haled
before the Lord Mayor on a charge of being a
resurrectionist. His landlady, while tidying his
room, found the remains of a child which Crabbe
had obtained for purposes of dissection, and thought
it was the body of a child of her own who had died
a fortnight before. Fortunately Crabbe happened
to enter and was able to allay her fears, since the
face of the infant had not been marred. After his
London experience Crabbe again returned to Alde-
burgh to practise, but again was unsuccessful, and
in 1780 definitely abandoned medicine and went to
London to try his luck in literature. At eighteen
he had won a prize for a poem, Hope, published in
IVheehle's Magazine, and a moral poem of his,
Inebriety, had been published in 1775. He induced
a London publisher to issue TJie Candidate, but it
was a failure and Crabbe went hungry many a day.

It is said that "Dearest Mira," whom he married
in 1883 after an engagement of eleven years, gave
him some financial aid. In such desperate straits
was Crabbe that he sought to enlist the aid of influ-
ential pohticians. In this way Edmund Burke be-
came interested in him, and secured the publication
of The Library in 1781. Besides, Burke got Crabbe
a "living" as an Anglican priest. He was or-
dained in August 1782, and flirough Burke's in-
fluence eventually became chaplain to the Duke of
Rutland. His first successful poem was The Vil-
lage, published in 1783. It was written to deride
the idyllic sentimentalism of Goldsmith's Deserted
Village, but The Deserted Village seems to have
sustained the shock. His next was The Newspaper.
Nothing more appeared until his Poems in 1807.
These were followed by The Parish Register, in the
same year, The Borough, three years later ; Tales in
1812 and Tales of The Hall in 1819. A large num-
ber of other tales in verse, published posthumously,
appear in his Works. His only prose writing was
a few medical disquisitions of a minor nature.

UNREGARDED WARNINGS.

There is no post helium for doctors, for theirs
is an unending fight against greed, ignorance, and
disease. One doctor who served during the war,
in France, has had to take a post at a mining station
in Mexico and says : "Bolshevist literature is being
circulated among the soldiers urging them to com-
bine with workmen to seize productive industries."

The seed is being sown. What is the mining
company doing even to mend existing health con-
ditions? Nothing. "There is no water near the
mine, and no springs nor wells except on the other
side of the mountain. The company brings water

January 8, 1921.]

EDITORIAL ARTICLES.

by railroad in tanks every day and fills the tanks
at hospital and American homes at cost of about
five hundred dollars a month. The poor Mexicans
have no provision, and carry water for family use
and for their animals from tanks about three or
four miles away and pay two cents a bucket.
Naturally there is Httle or no bathing, and I have
seen them washing several garments in two quarts
of water. Discontent is spreading. We may have
some excitement here, as there is considerable
bubonic plague about sixty miles down the valley.
It has been gradually encroaching on the highlands
from Tampico for about a year, and is slowly mov-
ing towards the interior. The company sent us
some plague serum, but I have little confidence in

it-"

Here is a case of a competent medical officer
hopelessly handicapped by insanitarv- conditions he,
alone, cannot mend, and who sees trouble ahead in
advancing plague. Added to this he sees Bolshev-
ism threatening, not unnaturally, among natives
who see rich mining companies take all they can
get at the cheapest cost and leave the countrv- worse
for their coming.

EDUCATING THE STAFF.

It is not always realized that all light thrown
on the condition of asylum and prison inmates must
come from those on the staff, and in judging fairly
a few reported cases of bullpng or neglect it must
be remembered that the nature of the insane and
criminal, their dogged determination to annoy those
in authority, their profanitv', their obscene language
and disgusting habits when such exist sorely try
the patience of the most enthusiastic in reform.
We are not speaking generally. There are many
in an asylum who seem sane, many in a prison
who appear not guilt}-.

How far education has influenced the staff of
the New Jersey State Hospital can be seen by The
Psychogram, issued monthly, and for which the
patients w-rite, not only write for, but print. The
October number is specially good in its contribu-
tions and clear pictures, the whole number is cheery
in its descriptions of the everyday happenings, its
poems and sketches. Only those who have worked
in an asylum can appreciate what it means to bring
out a paper even with the sanest patients' help.

The same feeling of respect should be felt for
those of the staff in the Minnesota State Prison,
through whose care The Mirror is issued, and for
which the prisoners write. The very ignorant often
imagine the ordinary criminals as always intent on
evil, the more charitable imagine them somewhat
weak in intellect, whereas there are those who com-

mit the most absurd and often atrocious crimes who
cannot be classed as feebleminded ; they may even
be supernormal in mentality.

These humane efforts to improve the wearj- days
of those detained within asylum and prison walls
should be welcomed even by the mean man, for
they will gradually save the State much money in
taxes for institutional upkeep.

NOT WANTED.

We have had too much of problems being tftrmed
unsolvable. Those who deem one most so often
know the remedy and will not apply it for fear of
antagonizing property owners, politicians, the church
or friends, and such men are now found urging
that the impecunious tuberculous should not be sent
to Texas .as there are no advantages in the climate
and light work is scarce. These socalled facts the
various boards of health desire to have circulated
with a \-iew to deter newcomers. They have been
faced with the problem of the impecunious tuber-
culous and this is their solution.

Now the truth is that with increasing knowledge
of disease, property owners in Texan towns have
begun to recognize the disadvantages of having a
State sanatorium near their land, and even land-
ladies advertise their rooms with a warning, "No
tuberculous taken." As to ad^'antages through cli-
mate, anyone who has lived at a place — say. El Paso
— has known and seen what a sojourn there will
do. How men who arrived limp, listless, wistful,
have soon been able to sit on the plaza or even
climb up on to the Meza. Moreover, the sanatoria
for the rich just pile up e\-idence of its healing
powers. As for light work, there is always plenty
in a rising communitv% and the hundreds of wooden
bungalows in course of erection in a new Texan
town generally provides it. To guard a town against
undesirable visitors is natiu-al, often justifiable, but
to use mendacity as a weapon is rather a low form
of warfare. The problem is, in realitv-, not one at
all, but merely a question how to keep up the price
of land and property if a disease is allowed to
hover and finally settle in the State. The answer
is to have a frsLnk declaration of how the settlers
obtained their rights to lands. Part of the early
procedure was to advertise the climate as health,
giving, and to disparage it when it came to a
question of taxes for a State sanatorium, or when
stifficient of the wealthy tuberculous had purchased
land and settled there.

BURGL.\RY ANT) DENTISTRY.
In these days when science figures so largely in
the work of detecting crime and often in the task
of committing it, the burglars would do well
to establish some evening lectures bearing on medico-
legal work. Fagin, in Oliver Twist, had classes
for the quick theft of handkerchiefs and jew-elrv-,
but the modem criminal is more intent on knowing
about the manufacture of bombs and poisons and
the distinction between human and animal blood
smears. At any rate, a word of advice as to fre-
quently seeing a good dentist might not be out of

76

NEWS ITEMS.

[New York
Medical Journal.

place. A burglar made a murderous attack on a
bailiff and his wife in their lonely cottage, but
escaped. A false tooth was found on the floor by
the local policeman, who treasured it up, and, some
time after, caught the man belonging to the tooth.
Doubtless, the man thereafter sought a more skilled
dentist.

News Items.

Italians Plan Hospital. — On December 22d
over two hundred Italian citizens of Brooklyn held
a meeting for the purpose of starting a drive for
the collection of $350,000 to build a hospital in Kings County. Human Rabies in New York. — Six cases of human rabies were reported to the Department of Health of the City of New York during the years 1919 and 1920. They all occurred in chiPdren four years of age, and all were fatal. Polish Doctors Victims of Typhus. — Cable dis- patches from Warsaw state that Poland lost four hundred doctors from typhus fever last year. There are only 4,000 doctors now in the country, which has a population of 28,000,000. Medical Monthly Changes Name. — With the December issue the name of the Medical Council, of Philadelphia, was changed to the American Physician. The publishers announce that the change is in name only, the organization remaining the same. Professor Bumstead Dies on Train. — Dr. Henry A. Bumstead, professor of physics at Yale University, died on Friday evening, December 31st, on board the train while on his way to Washington from Chicago. He was fifty years of age. He was on leave of absence from Yale, serving as chairman of the National Research Council in Washington. Western Surgical Association. — At the thir- teenth annual meeting of this association, held recently in Pasadena, Calif., the following officers were elected : Dr. Charles D. Lockwood, of Pasa- dena, president; Dr. Harry Ritchie, of St. Paul, vice-president ; Dr. Warren A. Dennis, of St. Paul, secretary (reelected). Next year's meeting will be held in St. Louis. New Work for League of Red Cross Societies. — The Council of the League of Nations has re- quested the League of Red Cross Societies to supply the personnel and materials to protect the health of the international force which will go to Vilna to supervise the plebiscite to determine the sov- ereignty of that district. Colonel Henry A. Shaw, of Worcester, Mass., has been sent to Vilna to make the necessary arrangements. Fatalities from Automobile Accidents in Lon- don. — Automobile vehicles of all classes killed fifty-one persons in London in November, 1920, compared with fifty in November, 1919. The Lon- don referred to is the metropolitan police district, which extends over a radius of fifteen miles from Charing Cross, and covers an area of roughly seven hundred square miles. About seventy per cent, of the casualties occurred in the day time, and thirty per cent, at night. Only two fatalities happened in November in the city proper, which is an area of just over a square mile around the Mansion House. Typhus Fever on Ocean Liner. — A case of typhus fever was found on the steamship United States as the vessel left Copenhagen, Denmark, on November 18th. The patient, with four contacts, was removed from the vessel at Christiana, Norway, and the vessel sailed from that port for New York on November 19th. Southern Gastroenterological Association. — At the annual meeting of the Southern Gastro- enterological Association, held recently in Louis- ville, Ky., Dr. George M. Niles, of Atlanta, Ga.. was elected president. Dr. Marvin H. Smith, of Jacksonville, Fla., was elected vice-president, and Dr. John W. Fitts, of Atlanta, reelected secretary and treasurer. Physicians Needed for European Service. — The American Red Cross Society announces that the services of a number of medical men are needed among the children of Eastern Europe. It is said that the service is particularly suitable for recent graduates. The remuneration will be sufficient to represent an adequate salary and living expenses. The need is urgent, and all who are interested in this work are asked to communicate at once with Dr. Charles W. Berry, 44 East Twenty-third Street, New York. Tri-State Medical Society. — The sixteenth an- nual meeting of the Tri-State Medical Society of Arkansas, Louisiana and Texas, was held recently at Texarkana, Texas. The following officers were elected : President, Dr. Frank H. Walke, of Shreve- port. La. ; vice-presidents, Dr. Leonce J. Kosminsky, of Texarkana, Ark., Dr. Spencer A. Collom, of Texarkana, Texas, and Dr. John A. Hendrick, of Shreveport, La. ; secretary. Dr. Netrie Klein, of Texarkana, Texas. Shreveport, La., was chosen as the place for the 1921 meeting. Infant Death Rate Falls in Great Britain. — The aimual report for 1919 of the Registrar General for England and Wales shows fewer deaths now occur- ring in childhood. Death rates by far the lowest on record are shown for 1919 from measles and whooping cough, while the low death rate from diarrhea has only once been bettered. The death rate at most ages of life shows a tendency to decline, except in the case of cancer. The excess of infant deaths in London over the average for the country which was noted as an exceptional feature of the 1917 and 1918 figures has disappeared. Certified Water. — Within the last twelve months the danger to railway travelers of infection with typhoid fever, dysentery, and other water borne diseases has been reduced to a minimum throughout the greater part of the country by the cooperation of the U. S. Public Health Service with the dif- ferent state boards of health in the testing of the water used on railway trains for drinking and cooking. Within the next few months, similar protection will be afforded to passengers on river and lake steamers and to ocean steamships sailing from American ports. This will tend to end the severe outbreaks of typhoid fever that have from time to time been traced to ships (especially to excursion boats), as well as to the probably more numerous but far less easily traced illnesses of rail- way travelers from similar pollution. January 8, 1921.] NEWS ITEMS. 77 Vital Statistics of New York. — During the fifty-two weeks of the year 1920 there were 72,874 deaths, corresponding to a rate of 11.90 in a thou- sand of population, compared with a total of 74,419 deaths and a rate of 12.39 in a thousand of popula- tion last year. During this period 11,279 infants died, a rate of 85 in a thousand births. During the corresponding period last year 10,639 infants died, a rate of 83 to a thousand births. Demonstration of Radium Treatment of Can- cer. — Under the auspices of the Health Depart- ment of the City of New York, a series of lectures will be delivered in New York during the month of January to emphasize the curability of many forms of cancer in the early stages by radium therapy. The object, as explained by Dr. Royal S. Copeland, health commissioner, is to allay the fear of surgery which, he believes, deters many persons from seeking treatment while the disease is in the incipient stage. It is announced that a radium ex- pert will assist in the lectures, exhibiting some of the methods of radium therapy. Surgeon Directs Operation by Wireless. — Dr. Patrick S. Burns, of Providence, R. I., chief surgeon on the Leyland liner Winifrcdian, directed by wire- less the setting of broken bones and the care of > internal injuries sustained by seamen on the Belgian steamship Mcnapier when that ship was battered by a hurricane. When an S. O. S. message from the Belgian steamship brought the Winifrcdian to her assistance, Dr. Burns attempted to put out in a life boat, but was prevented by the storm, so by wireless he directed the method of treatment in each case. The two ships lay alongside each other for three days, but the storm prevented any com- munication other than by wireless. At the end of that time the men were all reported as out of danger. Resolutions on Death of Dr. Meltzer. — At a special meeting of the council for the New York Society for Thoracic Surgery, the following reso- lutions were adopted upon the death of Dr. Samuel J. Meltzer: Whereas, On November 7, 1920, death removed from the roll of this society our distinguished colleague, Dr. Samuel J. Meltzer ; and _ Whereas, During his membership in this young associa- tion Dr. Meltzer has been an active worker and an ardent and enthusiastic supporter of the objects which called the society into being; and Whereas, By his formal communications as well as by his illuminating discussions, in fact by his mere presence, he has been a continuous source of inspiration to its mem- bers; and Whereas, His important discovery of overcoming the dangers of acute operative collapse of the lung by means of his world renowned "Intratracheal Insufflation" is an epoch making contribution to thoracic surgery; and Whereas, Doctor Meltzer was honored with the office of first president of the American Association for Thoracic Surgery, the offspring of this society; therefore, be it Resolved, That in the death of our colleague the New -York Society for Thoracic Surgery has lost one of its most valued and beloved fellows ; and be it further Resolved, That these resolutions be spread upon the records of this society and a copy be forwarded to his be- reaved family and to the medfcal journals. Howard Lilienthal, M. D. Willy Meyer, M. D., William H. Luckett, M. D. Carl Eggers, M. D., Secretary. Motor Accidents in Chicago. — The total num- ber of deaths in Chicago resulting from automobile accidents in the year 1920 is placed by Coroner Peter M. Hoffman at 559. That figure represents an increase of approximately twenty-five per cent, over the automobile deaths of 1919. In 1919, 420 persons met death in motor crashes. In 1918 the number of fatalities resulting from automobile accidents was 374. In the year just passed 5,757 coroner's cases were presented to Mr. Hoffman. Of that number physicians issued 2,144 death cer- tificates. The remaining 3,613 cases required coro- ner's inquests, and one seventh of them were auto- mobile deaths. Meetings of Local Medical Societies. — During the coming week the following medical societies will meet in New York: Monday, January loth. — Society of Medical Jurispru- dence; New York Ophthalmological Society (annual); Yorkville Medical Society ; Association of Alumni of St. Mary's Hospital, Brooklyn ; Williamsburg Medical Society. Tuesday, January iith. — New York Academy of Medi- cine (Section in Neurology and Psychiatry) ; Manhattan Dermatological Society; New York Obstetrical Society; Clinical Society of the Hospital and Dispensary for De- formities and Joint Diseases. Wednesday, January I2th. — Medical Society of the Bor- ough of the Bronx (annual) ; New York Pathological So- ciety ; New York Surgical Society ; Alumni Association of Norwegian Hospital ; Brooklyn Medical Association. Thursday, January 13th.- — New York Academy of Medi- cine (Section in Pediatrics); West End Clinical Society; Brooklyn Pathological Society. Friday, January J4th. — New York Academy of Medicine (Section in Otology) ; Eastern Medical Society of the City of New York; Flatbush Medical Society; Society of Ex- terns of the German Hospital in Brooklyn. €> Died. Baxter. — In Somersworth, N. H., on Monday, December 27th, Dr. Hemon Baxter, aged eighty-eight years. Davis. — In Lamanda Park, Ca!., on Thursday, December 23rd, Dr. Nathan Smith Davis, of Chicago, 111., aged sixty- two years. Freeman.— In Philadelphia, Pa., on Monday, December 20th, Dr. Walter J. Freeman, aged sixty years. Grant. — In Lynn, Mass., on Tuesday, December 28th, Dr. James H. Grant, aged seventy years. Hershm.\n. — In Alliance, Neb., on Monday, December 20th, Dr. Charles E. Hershman, aged thirty-five years. Kimball. — In Boston, Mass., on Tuesday, December 28th, Dr. Samuel A. Kimball, aged sixty-three years. De Kraft. — In Greenwich, Conn., on Friday, December 24th, Dr. Sarah L. De Kraft, aged eighty-seven years. KuNKEL. — In Salamanca, N. J., on Saturday, December 18th, Dr. Oscar F. Kunkel, aged forty years. LocKRiDGE. — In Ronceverte, W. Va., on Friday, December 17th. Dr. James P. Lockridge, of Minnehaha Springs, W. Va., aged fifty-eight years. Mills. — In Missoula, Mont., on Monday, December 6th, Dr. William P. Mills, aged sixty-three years. McMillan. — In New Egypt, N. J., on Friday, December 17th, Dr. William T. McMillan, aged fifty-two years. O'Brien. — In Ashland, Wis., on Monday, December 20th, Dr. William T. O'Brien, aged fifty-nine years. P.\GE. — In Bel Air, Md., on Wednesday, December 22nd, Dr. Robert S. Page, aged forty-six years. Taylor. — In Ridley Park, Pa., on Sunday, December 26th, Dr. Horace Furness Taylor, aged thirty-nine years. Wallace. — In Newport, Wash., on Tuesday, December 21st, Dr. Walter S. Wallace, aged thirty-seven years. Book Reviews MANUALS ON DIABETES. Patient's Handbook on the Treatment of Diabetes Mellitus. By Thomas W. Edgar, M. D., Associate Editor on Dia- betes, Western Medical Times ; Author of Psychology of Prognosis, Limitation of Starvation in Diabetes, etc. Boston: Richard G. Badger, 1920. Pp. 100. Diabetes. A Handbook for Physicians and Their Patients. By Philip Horowitz, M. D. With Twenty-seven Text Illustrations and Two Colored Plates. New York : Paul B. Hoeber, 1920. Pp. xii-196. Neuvas Orientaciones Sobre la Patogenia y Tratamiento dc la Diabetes Insipida. Par Dr. Gregorio ^Iaranon, de Hospital General. Madrid : Editorial Saturnino Calleia S. A., 1920. Pp. 13, 174. Much progress has been made in the treatment of diabetes. The manuals reviewed here have been written by speciaUsts whose names are familiar to the readers of the New York Medical Journal. For this reason these books should be of special interest to our readers. * * * Most medical writers take us back to Hippocrates, but, in this case, he had nothing to say about dia- betes, so the reader of Edgar's book is hurried on to a species of mortuary in which 11.775 persons lie dead of diabetes (1915), which makes him timor- ously inquire what brought them there, what pre- disposed them to so grim a fate. No age, no class, is exempt, answers the author gloomily. Has lovely woman no exemption? Yes, slightly beyond the man. Has race any exemption ? The Jews are particularly susceptible. Does heredity play any part? More in environment and association than by being a predisposing factor. Infection? It dis- claims any share. Dr. Edgar thinks nervous influ- ences a strong detennining factor, also head in- juries, typhoid, diphtheria, rheumatism, and some- times syphilis. Among theories as to the cause, Edgar gives his own, saying it is a complication of chronic intestinal stasis. The toxins formed in the intestinal track due to fermentation and putrefaction of carbo- hydrates and proteids in time cause a degeneration of the glandular structures with a resultant retarda- tion of function causing the body to lose its power to care for its sugar content. He considers the disease not primarily one of the pancreas but of the entire ductless gland system. Other glands than the pancreas are concerned in sugar metabolism, and when the secretion of one or more is interfered with diabetes follows. Sugar in the urine often causes needless worry. The amount the patient is able to assimilate is the safest indication of severity. No drugs figure in Edgar's treatment, but one thing will meet favor with some : he believes in alcohol when the diet is being reduced as it acts as a fat sparer and has direct value as food. Alco- hol is ideal in that it is entirely oxidized, leaving no byproducts harmful to metabolism. For the past year the author has been using a serum derived from the blood of rabbits, also an infusion derived from a plant which grows in Southern Italy in December and January. It is a kind of nettle, and its action is to cause oxidation in the body and make the sugar disappear. There is a graduated series of diet charts which would be attractive to any invalid. No bread on the menu, but bran cakes, made from stable bran, are permitted. A word of warning is given against the deceptive appearance of the healthy diabetic who is a whited sepulchre despite his ruddy cheeks. Boasting of his power to defy dietetic rules and yet preserve health, he one day feels drowsy, shortwinded, comatose, and heads for the tomb while the doctors sadly sigh, "We told you so." From such a fate may common sense and Edgar's helpful volume deliver us. * * * Anyone who has passed an hour or two in the consulting room of an internist knows the frequent inquiries which come from fussy or disconsolate patients over the telephone, particularly from dia- betics, imploring permission to eat a little forbidden food, or, complaining of pain, and being questioned, reluctantly admit that they have eaten to test their improved health or because they would not appear unsociable. The doctor sees no difference between suicide with a lobster salad and bichloride of mer- cury, since the effect of each is understood by the diabetic. Dr. Horowitz, suffering like his confreres from unreasonable and disobedient patients, has tried to mend matters by taking them into his confidence. He has exposed the mechanism of life and the causes of disharmony, the reasons for prohibition of some foods, the nutritive excellence of others. He has given simple tests for sugar which the patient himself can make. This will keep a sick one interested, for ninety-nine per cent, find their own insides a fascinating study. To the normal, healthy person who shovels food down in an absent minded fashion and thinks calories and vitamines are some form of disease, the diet charts seem both liberal and varied. Allowance is made for idio- syncrasies in food, extra portions are allowed as soon as they can safely be taken. One day a week is a Green Day, which simply means extra green vegetables and is not to be confounded with Arbor Day or Irish demonstrations. The author, though assured of the value of cultures of Bacillus bulgaricus, does not say it is as a cure, but says it helps to take care of and neu- tralize an existing autotoxemia and increases the time necessary for starch to be converted into dex- trose or glucose, so that smaller quantities of glucose are formed in a given time. Large doses are found to produce the best results. Diabetes, nephritis, arteriosclerosis, gout, and other forms of metabolic disturbance are ascribed to a form of autointoxication causing an interference with the functions of the ductless glands, or irrita- tion of these and other organs. This statement is based on personal research and animal experimenta- tion and is enlarged on in the book. There are excellent tested menus, recipes and analyses of food which will help the tired doctor and secure the cooperation of the doctored. The section on Juv- enile Diabetes will be useful to mothers and nurses in the difificult ta.sk of coaxing a child to eat what January 8, 1921.] HOOK KEl'lEW 79 he does not fancy. ' Any diabetic wlio reads the clear directions and warnings can no longer plead ignorance in provoking symptoms he is unable to relieve. * * * Dr. Maranon has written a very valual)le and complete treatise on diabetes insipida, with a bibli- ography which pretends to be complete on the subject ; inasmuch as the references number one hundred and forty-six, this claim to completeness seems justified. The essence of the author's views on the pathogeny of the disease may be said to be found in his conclusions stated at the end of the first chapter, namely, "almost absolutely all cases of diabetes insipida present symptoms which demon- strate the existence of a hypofunctional lesion of the middle and posterior lobes of the hypophysis." Consequently, his treatment is directed along the lines of supplying this deficiency in function of the pituitary gland. In this regard he is convinced of the inefficaciousness of drugs, restriction of fluids, salt free or low nitrogenous diets, hydrotherapy or electricity ; however, in those cases which show an evident hypertonia of the vagus, belladonna and atropine have been partly useful. Pituitary extract has been used by Maranon with uniform success, administered both hypodermically and by mouth ; whether a true cure can be effected remains to be seen, although this may be hoped for in a certain proportion of cases, always remembering that tumors of the hypophysis must be treated surgically. HOOKWORM AND MALARIA. Hookivorm and Malaria Research in Malaya, Java, and the Fiii fslands. Report of the Uncinariasis Commission to the Orient, 1915-1917. By S. T. Darling. M. D., M. A. Barber, Ph. D.. and H. P. Hacker, M. D. Publication Xo. 9. New York : The Rockefeller Foundation Inter- national Health Board, 1920. Pp. x-191. Parasites have been written about since earliest antiquity ; the commonest were known to the Egyptians, and we may believe that all early peoples, civilized or savage, knew a great deal about them, for hygiene as it figured in their religion deals much with precautions against them. So, to these men the sight of great scientists setting out on a far voyage to fight a worm, a fly, an ameba, and, re- turning some years after, not wholly victorious, W'ould have seemed quite a necessary thing. In this report are garnered two years' work, and some excellent pictures of the people who regard precautions as petty tyranny, and wash themselves, their clothes, their rice, in the same water, even defecating if convenient. It was not a matter of surprise that one place. Batavia, Java, had an inci- dence of ninet)'-five and two tenths per cent, with average number of worms forty-nine. The commission had a heavy , task in examining Chinese. Tamils, Fijians, Malays, Indians, and others, because the susceptibility varied, the health ; conditions varied, and certainly ideas varied among the people as to the use of worrying. Even the ! vulnerability of the worms in relation to vermicide I varied. Chenopodium was the usual antidote, but the Ancylostoma duodenale, a species of which the Chinese had the larger proportion, had the mouth part larger than the Necator. The anatomical dif- ference would enable the former to inflict more serious wounds in the mucosa, and cause greater anemia and re(iuired higher doses of vermicide. It was found well to express the hookworm species formula in percentages of ancylostoma, because that indicates the necessity of the higher dose. Seeing the many variations, it is impossible to ([uote adequately concerning hookworm and ma- laria. The report is so concise, so anxious to in- form, that the interested man will hurry to order it. The reading raises a doubt as to the real meekness of mortal man in calling himself a worm, even a vile one, seeing its power to torment and kill, while the wicked worm mu.st curl up in laughter at the abortive efforts to get rid of him. THE INDUSTRIAL CLINIC. The Industrial Clinic. A Handbook Dealing witli Health in Work. By Several Writers. Edited by Edgar L. CoLLis, M. D. (Oxon.), M.R. C. P.; Talbot Professor of Preventive Medicine in the University of Wales ; Late Director of Welfare and Health, Ministry of Munitions, and H. M. Medical Inspector of Factories. Modern Clinic Manuals. New York: William Wood & Co., 1920. Pp. xii-2.59. The "several writers" certainly have done their work well, but those with an unthinking mind would do well to avoid this volume, be they employers or employed, for no one can gain knowledge with- out increase of responsibihty ; theirs is then the sin of those who know the right and do it not. The employer may no longer consider his workpeople as hands, or a staff, or a gang or .shift : they are men and women with brain and heart, stomach and lungs, and emotions, as he himself has. He may still continue to engage hands, but those same hands, influenced by socialist meetings and poor cooking, bad air, and the lack of a tubbing, now yield ugly missiles, vocal and instrumental, for retaliation when consideration by the employer is lacking. Doctors, economists, theologians, philanthropists, are urging the employer to this duty because of the increased output of work it will eventually mean, and the gradual, sobbing subsidence of the waves of the high sea of revolt. There will also be the .social, civic distinction of being a model employer dis- countenancing greed and graft, petty tyranny, and selfish neglect. But he has the uphill task of contending against suspicion and ignorance. "Just to get more work out of us," growl the people. "Spying on us with his blooming tests. The other day old Bill was laid off ; too slow, not up to new machinery, and, un- knowing, his own young daughter got the job." Then, those for whom gloves and masks, spectacles and special overalls, are provided, are the very ones not to use them. The precautions worry them, and, after all. they may not be the next ones to suffer. Now, granted that the boss has advertised for. selected, and suitably placed the new hand, our several writers press around and say he must not overwork him ; must give him well ventilated, well warmed workrooms ; must eliminate or guard against the use or incurrence of things dangerous to health ; must provide a medical ofificer, and, where possible, a canteen, cloak rooms, adequate toilets; The employer has a hard task. Let him be thankful 80 BOOK REVIEWS. [New Medical York Journal. his liabilities do not yet extend as far as suitable housing. And do these men write only for employers? No ; for any who are concerned, voluntarily or involuntarily, with the great world of labor. They begin with treating the engagement of the worker on medical and psychological grounds, then indus- trial efificiency, fatigue, environmental and per- sonal hygiene, ambulance and first aid work, physi- ology, and economy of food supply; finally, the employment of women. They ask for chief auditors of their book, factory medical officers and welfare workers. The material has been carefully gathered by well known men. Dr. Leonard Hill writes clearly and usefully on Food Values in Relation to Occupation. All the men were daily using their energies during the war, and are not writing merely to make a book but to make men. THE NERVOUS HOUSEWIFE. The Nervous Housewiie. By Abraham Myerson. Bos- ton : Little, Brown & Co., 1920. Pp. 273. Long ago, B. C, there were bitter complaints about women ; living with a scold was like "a per- petual dripping on a very rainy day" ; they beguiled the hundred per cent, young men from virtue's path. They liked walking about Fifth Avenue, Jerusalem, in "changeable suits of apparel," mantles, hoods and veils, crisping pins, ornaments on their legs, chains and bracelets. They were sly and subtle Rachaels and Delilahs, liking to mix up with politics as did Jezebel and Herodias, or to singing Socialist songs, like the Virgin IMary. Curiously, the men did not see anything unwomanly in the deeds of a Jael or Judith or any such stern minded woman. Taking century long strides through the ages, we find there were always men who said there never was a time like that present,, with women so ab-so-lute-ly frivolous and damaging. Roger Ascham was doubtful of any good at all in them ; Thackeray deluged them with cynicism ; Kipling's poem is as bad as Solomon's doleful reproaches, and he certainly saw plenty of thetn. That famous answer to the query, "Who can find a virtuous woman?" ascribed to Solomon, was written by one of the Mrs. Solomons, and taught to her son, Lemuel. Here we are, then, in 1920, with all the world whirling more swiftly, with manners and customs changed, with no doors closed to the independent young women, expecting her to settle down in humble flat or maisonette and find full joy in domesticities. Even in 1817 she was condemned for seeking inky diversion, for Lady Morgan was thus addressed in the Morning Post: Lady, lay down the pen ; take up the needle. Mend shifts or stockings : darn, a decent sight. But, if thou can'st not sew, thrum tweedle-deedlc. In short, fair dame, do anything but write. There is found in Dr. Myerson's book neither condemnation nor mockery, but a sympathetic com- prehension of that which makes nervous house- wives. One disturbing element is the nonconfluence of two ideas : one that marriage implies the depend- ence and essential inferiority of woman, the other that the man and woman are equal partners in the relationship. When this question is settled, the home will be reorganized in relation to the new belief. It has also to be borne in mind that the child, too, has changed. The mother has to deal with a more alert, more sophisticated, more sensu- ous child, and tots of five years are sent to the kindergarten because they wear their mothers out. Restricted childbearing is prevailing more and more ; had the woinan of the past known how, she also would have had fewer children ; but the author speaks plainly and wisely on the other side- sterility. The chapter on The Nature of Nervous- ness will enlighten the young wife who regards neurasthenic, neurotic, psychasthenic, hysteric, as interchangeable terms. In The Types of House- wife Predisposed to Nervousness, the wife may find her own picture ; she has plenty to choose from. There is the fussy woman, the jealous, the hyper- sensitive, the ultrameek inwardly rebellious, the nagging, the hysterical, the dreamer. But it is just to say that the author deals with these same con- ditions as occurring in husbands. Conditions arising from original sin or constipation, from too much conscience or too much candy, from deadly dullness or ainusement saturation, are thoroughly sifted; also the more serious one of the lack of passion and the quick divorce. Every sensible w'oman will take her just share of blame as she reads ; every foolish one will demand her share of excusation ; every husband will take new views of life and his wife. ^ New Publications Received. {IVe publish full lists of hooks- received, but we acknowl- edge no obligation to review them all. Nevertheless, so far as space permits, we review those in which we think our readers are likely to be interested.] THE SILENT MILL. Bv HERMANN SuDERMANX. New York: Brentano's 1920. Pp. 204. LAOTZu's TAG and wu WEI. Translated by Dwicht God- DARD. New York: Brentano's, 1920. Pp. 116. THE STORY OF A STYLE. By WiLLIAM BaYARD HaLE. New York : B. W. Huebsch, Inc., 1920. Pp. 303. bergson and personal REALISM. By Ralph Tyler Flewelling, Professor of Philosophy in the University of Southern California. New York, Cincinnati : The Abing- don Press, 1920. Pp. 304. praktikum der klinischen chemischen, mikroskop- ischen und bakteriologischen untersuchungsme- THODEN. Von Dr. M. Klopstock, San-Rat, und Dr. A. Kowarsky in Berlin. Sechste, umgearbeitete und ver- mehrte Auflage. Mit 40 Textabbildungen und 24 farbigen Tafeln. Berlin, Wien : Urban & Schwarzenberg, 1920. Seiten, xv-518. common infections of the kidneys with the colon BACILLUS AND ALLIED BACTERIA. Based on a Course of Lectures Delivered at the London Hospital. By Frank KiDD, M.B., B.C. (Cantab.), F.R.C.S. Eng., Surgeon of London Hospital ; Surgeon-in-Charge of Genitourinar\- Department, London Hospital ; Member of the International Society of Urology, etc. With an Additional Lecture on the Bacteriology of the Urine by Dr. Philip Panton, Clini- cal Pathologist, London Hospital. London : Henry Frowde (Oxford University Press) and Hodder and Stoughton, 1920. Pp. xx-331. Practical TTierapeutics and Preventive Medicine A Compendium of Treatment and Prophylaxis, Original and Adapted Treatment of Tumors of the Female Bladder. — William Neill (American Journal of Surgery, December, 1920) states that the method of treat- ment during the past five years has drawn further and further away from any operative procedure, except in the cases of massive tumors. The treat- ments can be given with great ease and accuracy through the Kelly cystoscope. The best results have been obtained by the use of radium. The flat tumors with broad sessile bases are treated by implanting (or shooting) directly into the tumor, tiny capillary glass tubes containing from three to five ma. of the radium emanation, which are left permanently, and which give a tremendous radia- tion throughout a long period. From one to several of these spicules may be implanted, depending on the size of the growth. This form of treatment should never be repeated under four to six weeks. In association with this method and also for the smaller definitely pedunculated tumors the emana- tion attached to a sound and encased in a brass or platinum capsule is used, which is held directly on the tumor. For this the equivalent of one gram of radium in the form of emanation and on an average of from five to ten minutes on each existing tumor is used. ' Such cases are ambulatory or ofiice patients and are examined and treated on an average of once a week for from four to five weeks. At the end of that period all treatments are discon- tinued and the patient allowed to go off for six weeks. Then another examination is made and the treatments again instituted, depending on the amount of trouble remaining. With this method of treatment, instead of putting the patients to. bed and exposing them to the risks and discomforts of an operation, they are handled simply as office cases, and in the meantime they lead their regular lives at home. Patients are never discharged as cured, but even after the last vestige of trouble has disappeared they are instructed to report at regular intervals for examination. The tendency to recurrence is so great that in this way the recurrence is treated as soon as it becomes evident. Treatment of Persistent Bone Sinuses. — Charles William Peabody (Surgery, Gynecology and Obstetrics, November, 1920) states that in the year following the armistice about five hundred cases of bone sinuses following gunshot wounds came under observation for varying periods of time. These had presented an unusually stubborn surgical problem and in spite of prolonged surgical treatment litde progress was being made toward a cure. From treatment of about half of these a procedure was evolved which led to the clinical cure of the great majority. It was found that the presence of an infected bony cavity was the essential cause; that a revision operation sufficiently radical entirely to eliminate this faulty configuration was the first step required; that the concomitant infection could be effectively controlled and terminated in a compara- tively brief time by careful wound treatment based on physiological and antiseptic grounds. It thereby became possible, as well as desirable from the func- tional viewpoint, to close these wounds by a bold reconstruction operation. Persistent bone sinuses are a very common and a very serious complication of gunshot wounds producing compound, comminuted fractures, unusu- ally resistant to ordinary surgical treatment. A system of operative and postoperative procedure directed against the underlying etiological factors has been devised after considerable experience which in a high percentage produces a clinical cure. Such a method must stand the further test of late results before it can be regarded as the means of permanent cure in every case. Treatment of Stricture. — A. Ravogli (American Journal of Surgery, December, 1920) states that the treatment of urethral stricture has for its aim the enlargement of the lumen of the urethra and main- taining its enlarged calibre by dilatation. Dilatation is effected gradually and gently by the use of sounds, which, massaging the scar tissue of the urethra, causes its absorption. The maximum of effect should be produced by the minimum of effort, for the effect is due not to the pressure of the sound, but to its mere contact. Passing a sound by force, will tear and bruise the mucous membrane and consequently increase the inflammatory reaction. A steel sound must go in without effort. In this way the presence of the sound will be able to lessen the congestion at the point of contact, correct the irregularities in the canal and stimulate the deeper tissues to a reac- tion so as to soften the cicatrix. The method of forced dilatation and of divulsion, which some years ago were largely applied with serious consequences, have been abandoned. When the stricture is yet soft or in a semifibrous stage, it can be easily re- moved by prompting the reabsorption of the infiltrated elements by means of gradual dilatation. Treatment of Urethral Stricture. — Edgar G. Ballenger and Omar F. Elder (American Journal of Surgery, December, 1920) state that the best method of treatment is by gradual dilatation with sounds and the Kollmann dilator until the urethra has been dilated to a size considerably larger than normal in order to allow for the contraction that will follow later. The dilatations may be given with intervals of one to five days according to the reac- tion which follows. As a rule, the urethra should not be dilated again until the irritation of the previ- ous treatment has subsided. The dilatation should be gradual, because overdilatation at any one time is undesirable for the obvious reason that if the damage to the constriction is gross or massive, it will be repaired by scar tissue and the stricture will ultimately be made worse. The object in dilating the constriction is to cause a necrosis of the most constricting fibres by damage so slight that it will not be repaired by scar tissue but will undergo absorption, thereby lessening the constriction. It may become necessary or advisable to perform an 82 I'RACriCAL THERAPEUTICS AND TREl'ENTIl'E MEDICINE. INew Yokk lEDicAL Journal. internal urethrotomy which is the phm to follow in incising strictures in the anterior urethra. Too much hemorrhage is likely to follow if this opera- tion is done in the deej) urethra, the external perineal urethrotomy is the operation of choice in this region. The following are some of the reasons for incising uretliral strictures ; resilient ones which (juickly recontract after dilatations ; those which for other reasons do not respond in a reasonable time to adequate dilatations ; strictures too extensive or too tight for gradual dilatation ; and occasionally where the patient lives in a 'place too remote from a surgeon to employ the dilating method. External perineal urethrotomy is indicated in tight or resilient strictures of the deeper part of the urethra, that is, in the region near the external sphincter ; furthermore, this operation is required where there is complete or nearly complete ob- strtiction of the urine; for infiltration of urine and where there is stone in the bladder complicating the stricture. It is of great importance to pass an in- strument or a filiform through the urethra into the bladder to act as a guide in incising the constriction. This should be done before the anesthesia is started. The perineal incision is made down to the point of the instrument in the deep urethra, then a probe pointed gorget is passed through the stricture into the bladder. When unable to pass an instrument, we have recourse to one of two methods. First: Bore through the stricture with the forefinger until the stricture is passed. Second : Suprapubic cystotomy should be performed and the dilated part of the urethra back of the stricture found by retro- grade sounding. A large catheter is fixed in the urethra after external perineal urethotomy and allowed to remain in the urethra for ten days. The bladder is irrigated daily through the catheter with a saturated solution of boric acid. Subsequent dilatation should be followed as in dealing with ordinary dilatable strictures. Treatment of Ruptured Urethra. — J. Richard Allison {Military Sttrrjcon. September, 1920) con- cludes as follows : 1. When the diagnosis of rupture of the urethra has been made whether complicated by fracture of the pelvis, ruptured bladder or what not, a perineal section should be done immediately. 2. A suprapubic operation should not be done unless it has been found by examination that the bladder wall is ruptured and then only for rejjair of the bladder wall. 3. A suprapubic operation should not be done merely for retrograde catheterization until the operator has failed after diligent search to find the proximal end of the urethra. 4. The torn ends of the urethra should be sutured with as good anatomical approximation as possible. 5. The catheter should be left in the urethra until the wound is healed sufficiently to prevent a peri- neal fistula. 6. The aftercare should always be considered the important point in obtaining good results. 7. Sounds should be passed two or three days after the catheter is removed, and then at intervals for a long period depending upon the nature of the stricture. Treatment of Suppurative Cystitis. — ^Augustus V. Wendel {/Imcriccm Journal of Surgery, Decem- ber, 1920) asserts that the most important elements in the treatment of purulent cystitis are to keep the bladder continuously clean and to improve the nutrition of the local tissues. The vesical membrane being more or less ulcerated and covered witli firmly adherent mucopurulent masses, often incrus- tations, the futility of irrigations, as ordinarily administered, becomes evident. Such bladders are therefore cauterized with solid silver nitrate, ful- gurated and burned with the actual cautery practically through the whole thickness of the blad- der wall, but very few are cured because such etTorts are circumscribed. Treatment of Wounds of Knee Joint. — W. R. Owen (American Journal of Surgery, August, 1920) gives the following conclusions in regard to the Willems method of treatment: 1. All surgical methods of draining the knee joint in suppurative arthritis have certain drawbacks. 2. The Willems method in suppurative arthritis produces free drain- age of pus, promotes circulation of synovial fluid with maximum power of resistance, and stimulates blood supply to the joint. 3. The practical require- ments of treatment are: a, free drainage, and. 1). active movement. 4. Reports have shown that in about fifty per cent, of the cases treated a useful mobile joint has been obtained. 5. The Willems method should not be employed if delayed until the fulminating stage has been reached. Treatment of Old Hip Dislocations by Reduc- tion. — J. J. Buchanan (Surgery, Gynecology and Obstetrics, November, 1920) states that: 1. Trau- matic hip dislocations may be considered old at the end of four weeks. 2. Reduction by manipulation is rarely successful after that time, owing to forma- tion of connective tissue, which fills the acetabulum and' binds down the head and neck. 3. Reduction by open incision is to be preferred in nearly all cases of old hip luxations and with modern methods is attended with but little danger. 4. Preliminary traction by Buck's extension is of advantage. 5. The actual replacement of the head, after the acetabulum has been emptied and the head and neck released, is best accomplished by manipulation or the use of levers with manual and body traction. 6. The result is often ideal and, in the cases reported, has been good in eighty per cent. Management of Foot Abnormalities. — Tom S. Mebane (Military Surgeon, October. 1920) states that from the experience gained in dealing with large numbers of men in the Army camps, the fol- lowing conclusions may be drawn : A foot may be considered normal when there is unrestricted joint motion and the line of weight bearing passes through the fore foot. Foot trouble can be prevented by wearing proper shoes, by correcting faulty attitudes, I)y care to prevent overtaxing, by eliminating focal infections and by the use of exercises to strengthen the foot muscles. Symptoms referred to the feet are encountered in many conditions. The cure of static foot defects is dependent upon muscle training. Mechanical correction is to be regarded only as an aid to treatment. January 8, 1921] PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. 83 Treatment of Wrist Injuries. — Mauchet and Mauchet {American Journal of Surgery. August, 1920) state that retrolunar luxation of the carpus demands reduction, hke all other dislocations, even when associated with fracture of a carpal bone, or nerve lesions. The only possible danger in reduc- tion exists in those cases where the semilunar is dislocated 90°, or where the lesion has existed for more than a month. But even if intervention is delayed for more than a month, reduction is feasible and effectual. It should be done under general anesthesia. The surgeon should grasp the hand of the patient firmly, and exert traction in the direction of the axis of the forearm, at the same time moving the wrist slightly so as to make it supple. The hand is then brought into dorsal flexion, while traction is maintained and inclined slightly to the ulnar side. At the same time, pressure is exerted gently with the thumb over the palmar surface of the semilunar. Finally, the surgeon moves the hand quickly from dorsal to palmar flexion. During this manipulation the semilunar may be felt slipping into place. This is followed by immobilization for four or five days, hot baths, hot air, gentle and slow mobilization. In case the semilunar is fractured, or the condition has lasted more than one month, reduction should not be attempted ; the semilunar should be removed under local anesthesia, with the superior fragment of the scaphoid, if fractured. The incision is made on the palmar surface just within the palmaris longus. Infective Neuronitis. — Foster Kennedy {Ar- chives of Neurology and Psychiatry, December, 1919) observed several cases having many of the recognizable symptoms of acute polyneuritis, that presented unmistakable evidences of involvement of the spinal roots and of the central nervous system as well. In some of the earlier cases the main incidences of the disease fell peripherally, with occasional signs of root involvement, produced probably by ascending lymphogenous extension. One case emphasized the necessity of including more than the peripheral change in the conception held of the condition as a morbid entity. A study of the sections revealed a patchy neuritis in the peri- pheral nerves, and a degeneration of the cells in the ventral and dorsal cornua, and especially in the cells of the posterior ganglions. Similar but more benign changes were found in the deeper layers of the cerebral cortex and in the cells of the pontine nuclei. A small round cell infiltration was found around the ganglion and cornual cells, but never around the meningeal vessels as is usual in polio- myelitis. The ependyma of the spinal central canal showed constant extensive proliferation. The men- inges were nonnal. Small quantities of an emulsion of the affected spinal cord preserved in glycerine injected into monkeys subdurally produced the dis- ease clinically after an incubation period of from five to seven weeks, and histological examination of the nervous tissue of these animals revealed the same conditions as found in man. The disease was further produced by inoculations from monkey to. monkey. Nervous tissue from fatal cases and also from monkeys affected with the disease were in- vestigated bacteriologically and positive results were secured. Minute rounded bodies were found which were arranged irregularly or in pairs. This or- ganism inoculated subdurally in the monkey repro- duced the disease clinically and pathologically, and was recovered later from the cerebral cortex, a con- sideration that gave emphasis to the present con- tention that the problem was one of a widespread neuronic infection. The Value of Large Single Doses of Digitalis in the Treatment of Heart Disease.— G. Canby Robinson {Southern Medical Journal, June, 1920) advocates the administration of the tincture of digitalis in large single doses as a useful method of treatment in certain cases of heart disease, pro- vided the tincture is standardized, the dose regulated, and the patient kept under close observation. This method not only brings the heart rapidly under the influence of the drug, but also affords a more accurate means of studying its effect than the older methods of small repeated doses. The use of large single doses is apparently not dangerous under specified conditions. Problems of the relation of dose to body weight still need solution. The bene- ficial effect of digitalis in cases with cardiac ir- regularity caused by auricular fibrillation is espe- cially emphasized by experience with large single doses in this condition. Blood Transfusion. — E. R. Arn '{Ohio State Medical Journal, August, 1920) concludes that salt solution will not raise the blood pressure the second time. Transfusion of blood alone will save thr patient. The citrate method is the method of choice, because of the ease of application and preservation of important blood vessels for future transfusions or other intravenous therapy, should occasion re- quire. Transfusion is a specific for hemorrhage in the newborn. In hemorrhagic diseases it will re- place blood loss, stop the hemorrhage, but not cure the condition. Transfusion saves delay and de- creases mortality in cases with secondary anemia requiring operation, such as fibroid tumors and jaundice. Transfusion of blood opens a new field of therapy in the treatment of chronic infections. Most reactions can be averted by making correct group tests and transfusing from the same group except in extreme emergencies. Diagnostic Significance of Inspiratory Move- ments of the Costal Margins. — C. F. Hoover {American Journal of the Medical Sciences, May, 1920) says that in interpreting the inspiratory move- ments of the costal margins one must study the symmetry and asymmetry not only of the entire costal margins, but of the inner and outer portions of each costal margin. Movements of these mar- gins are modified with changes in the curve of the plane of the diaphragm, by paresis of either the diaphragm or the intercostal muscles, and by synechia between the diaphgram and the ,thoracic wall. Such studies improve the accuracy with which one differentiates between infraphrenic and supraphrenic disease, and enable one also to esti- mate the conformation of the heart and the size of the pericardial sac, and to differentiate between lesions which cause phrenic displacement and those which do not modify the plane of the diaphragm. Proceedings of National and Local Societies AMERICAN PEDIATRIC SOCIETY. Thirty-second Annual Meeting, Held in Highland Park, III., May 31, June 1 and 2, 1920. The President, Dr. Thomas S. Southworth, of New York, in the Chair. (Continued from page 44.) Blood Findings in a Child Five Years After Splenectomy. — Dr. Howard Childs Carpenter, of Philadelphia, presented in detail the average results of thirteen blood examinations in a white boy, ten years of age, who had had his spleen removed five years Ijefore for familial hemolytic icterus of the Chaufifard-Minowski type. The re- sult of the operation was satisfactory, and the case was reported in the literature a few months later. The child's present condition showed him to be an active, intelligent child of nervous temperament, with good muscular development and scant adipose tissue. He was six pounds under weight for his height and age, had a faint mitral regurgitant mur- mur, with no demonstrable hypertrophy. The thy- roid was not enlarged, and there was no jaundice or ascites. The external lymphatic glands were moderately enlarged. The tonsils were enormously hypertrophied. The average of the thirteen blood examinations made during the last six weeks showed hemoglobin eighty-two per cent., red cells 4,288,000, and white cells 15,000. No Howell- Jolly bodies were found. Prior to operation the hemoglobin was as low as twenty-three per cent., and the red cells were down to 2,020,000. There was still present evidence of bone marrow regenera- tion, as .shown by the high color index, the con- tinued leucocytosis, moderate chromatophilia and poikilocytosis, high transitional and eosinophile counts, and finally reticulation of the erythrocytes. There was an unusually quick coagulation time in .spite of a rather low platelet count, indicating in this case either a rapid availability of the platelets for the purposes of coagulation or an increased amount of prothrombin in the platelets, or a large percentage of macroplatelets. The low platelet count was simply the continuation of the condition which undoubtedly existed before the splenectomy, as it was well known that cases of hemolytic icterus showed low normal values, sometimes even less than 200,000. There was also evidence of lymphatic activity shown by absolute lymphocytosis, and by the enlargement of the external lymphatic glands and tlie very large tonsils. Food Requirements of Children after the First Year. — Dr. L. Emmett Holt, of New York, exhibited a number of charts showing the results of an attempt to estimate the total caloric needs of healthy f children over one year of age. This total was determined by the four factors which made it up, namely: 1, basal requirements; 2, needs for growth ; 3, needs for activity ; 4, loss by excreta. For basal needs the curve of Benedict and Talbot had been adopted. The per kilo requirement dimin- ished steadily from one year to the completion of growth. Growth needs were calculated frorri the rate of increase in height and weight for the dif- ferent years ; these would naturally be greatest at periods when growth was most rapid. The loss in excreta at all ages was practically ten per cent, of the calories taken. These three factors, though sub- ject to individual variation with different children, were as averages uniform and irreducible. The only factor which differed greatly with different children was the needs for activity. A child with average- activity used up nearly one half his caloric intake in this manner ; the very active child much more than this. The total caloric needs for the average child were greatest during the period of most active growth ; in boys, fifteen to seventeen years; in girls, thirteen to fifteen years. At this period their needs exceeded those of adults with moderate activity of both sexes. The adolescent boy required four thousand calories daily. The average per kilo needs for boys was one hundred calories at one year; this gradually fell to eighty at six years ; it was then practically constant to six- teen years, when it gradually fell to the adult average at nineteen years. In general, a little more fat, a little more protein, and a little less carbo- hydrate were required by the child than by the adult. The Effort Syndrome in Children and Young Adults. — Dr. Charles Gilmore Kerley, of New York, stated that during the late international war English army surgeons learned that when certain recruits were put to prolonged hard work at drills, hikes, and other hard exertion, they failed to mea.sure up to the endurance .standard required of the soldier in the field. To this condition Dr. Thomas Lewis applied the term effort syndrome. The condition was described by Friedlander and Freyhof as constitutional neurocirculatory asthenia. The boy or girl who might qualify for the effort syndrome class came to the physician with the typical story, which, condensed, meant that there was an absence of capacity for sustained effort, both mental and physical. Wherever endurance was re- quired he failed. In girls these constitutional peculiarities might attract less attention and be more readily excused when present. Among animals, those of defective capacity for economic reasons usually had a short career. The defective function- ing human, however, if well born, was urged and forced and stimulated to accomplish what was not in him. Millions of dollars were wasted on youths who were physically and mentally unable to meet the standard set up by ambitious parents and friends in an effort toward their socalled higher education. The highly trained teaching talent of our preparatory schools and universities was wasted in part on poor student material, twenty-five to fifty per cent, of which should be scrapped and put to productive occupation. Before a boy was permitted to avail nimself of unusual educational advantages it .should be determined that he was worth it. The high school should serve as a clearing house. In addi- tion to mental attainments recjuired for college entrance it should be required that a candidate sub- mit testimonials as to physical fitness and mental January 8, 1921.] PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES. 85 capabilities from the head master or high school principal. What was aeeded was expert occupa- tional diagnosticians who would aid in placing the boys at work for which they were fitted. The boy who belonged to the class under discussion should leave school at the age of fifteen or sixteen years and take up business. In order to make a reason- able success the occupation should be one which was not strenuous. It was unusual to find persons of this type the ofifspring of strong, vigorous young persons. In the majority of instances they were the offspring of the weakly woman of little resist- ance and of lessened endurance capacity. A strong, vigorous mother would do much to offset the influ- ence on progeny of a weakly male. The progeny of vigorous males was greatly reduced by inferior mothers. Frequent childbearing had apparently been a factor in some instances. The necessity for a great deal of attention to the physical development of those who would some day be mothers was a very urgent need. Further Development of Infants' Hospital. — Dr. Henry I. Bowditch, of Boston, said the present day tendency among hospitals was to de- velop the scientific side and its laboratories so as to bring them closer to the clinics. This valuable information must be properly weighed to be of true service, for we were deaHng with the delicate human body and mind and not with test tubes, and common sense and experience played an important role. This idea was being exemplified in the "On Shore" Department of the Boston Floating Hos- pital, which was being worked out on the basis of a ten bed clinic. This new development had been made possible by the generosity of a few friends, which had permitted the purchase of three small adjoining apartment houses which he had had re- modelled. The building and equipment had cost$45,000. . Ten was felt to be the best number of
patients, as they could be more readily followed
clinically, scientifically, and socially. This clinic was
held in two wards and the necessary isolation room,
under the expert care of three nurses. The wards
were so divided that there was less noise and the
children were able to have perfect naps, morning
and afternoon ; symptoms dependent upon restless-
ness, vomiting, etc., were markedly decreased
thereby. The clinic was so manipulated as to give
five new patients monthly. The scientific labora-
tories, chemical and bacteriological, were brought
into close proximity, making consultation easy, but
carefully separated so that noises, natural odors,
etc., did not penetrate. On Tuesday afternoon of
each week a health clinic, composed of 150 famiHes,
was held under the guidance of an assistant visiting
physician. On Wednesday the return "family con-
trol" clinic was held, in charge of a visiting phy-
sician. Two clinics were held for weighing the
children, getting clinical histories and giving treat-
ment.

Since opening on December 15, 1919, thirty
cases had been received, twenty-three of which
were diagnosed as regulation of feeding and mal-
nutrition in different degrees. It was the plan to
admit only nutritional cases, infection being care-
fully guarded against. The study so far had been

to organize methods of attacking the question of the
different food elements in growth and lack of
growth. Each case was to be examined completely,
clinically, chemically, and bacteriologically. The
plan was to have patients return at definite periods
for chemical and bacteriological tests, physical and
mental examination, for ten years. In this way
they followed the development of body and mind.
A weekly clinic to meet the parents had proved
satisfactory, allowing personal touch to impress the
parents with the miportance of physical care, proper
dietetics and discipline. In time groups of i)arents,
developing along natural lines, would be formed.
In this way they hoped to understand the mental
capacity of the parental group and adapt their
ideas to their particular peculiarities ; thus compre-
hending the good points of diet, life, etc., of the
different races, they hoped to lead them to a better
understanding of child life. It was hoped that this
beginning might lead others to establish similar
"small enough" institutions for the same study
and for the protection of their medical work. They
were under the management of the Boston Floating
Hospital trustees, who considered it a good ten
years' experiment. They would get perhaps sixty
patients a year, which at the end of ten years would
mean six hundred, and then they would be in a
position to talk of their results.

The Misuse of Milk in the Diets of Infants and
Young Children. — Dr. B. Raymond Hoorler, of
Detroit, stated that the value of milk as a food l)Oth
for adults and children had been exploited during
the past few years to such an extent that its use
was being much increased. This had inevitably led
to many dietetic errors, particularly in the group
of children between the ages of one and six years.
These errors might be classified under the headings :
1. Prolonged use of milk as an exclusive article of
diet. 2. Increased quantities of milk given along
with other foods. Milk might not only be used too
long as an exclusive article of diet and in excessive
quantities with other foods, but its nutritional value
might be injured by boiling. The laity were taught,
and rightly so, that milk was an ideal breeding
place for germs, and that the growth of these germs
might be inhibited by keeping the milk on ice or the
milk might be brought to a boil and then covered.
Through this teaching the printed instructions
accompanying certain patent baby foods, he believed,
the use of boiled milk was becoming more prevalent
and many injuries to nutrition occurred.

Doctor Hoobler exhibited charts showing the diets
usually given between nine and twelve months, be-
tween one and two years, and between three and
five years, and the relative proportion of the day's
calories supplied by milk when one quart was fed;
viz., eighty per cent, between nine and twelve
months; fifty-eight per cent, between one and two
years, and fifty per cent, between three and five
years. The relative proportion of different food
elements which was fed when one quart of milk
was ingested with other foods was also shown, the
fat proportion being relatively high and the carbo-
hydrate relatively low. The amount of overfeeding
above the basal metabolism which took place when
one quart of milk was fed was also shown. Often

86

PROCEEDINGS OF NATIONAL AND LOCAL SOCIETIES.

[New
Medical

York
Journal.

the child would refuse spoon feeding and take only
milk, thus making a bad matter worse, since this
habit robbed the child of minerals which should
come to it in fresh fruits, vegetables and cereals, not
to mention the vitamine and antiscorbutic properties
which these foods possessed.

A second chart showed the caloric value and pro-
portion of food elements when one pint of milk
daily was fed in addition to other foods, the amount
given being the same as in the first chart. This
chart showed the total calories reduced to within
normal requirements, the proportion of fat and
carbohydrate being nearly interchangeable, thus giv-
ing the child ample calories to use up in its activities.
It also showed lowering of the protein down to the
maximum for growth, wear and tear. Children
given such a diet were free from vomiting and
stupor accompanied by acetonuria so prevalent in
children who had been fed a quart of milk daily
in addition to a full diet. The propaganda urging
the use of a quart of milk daily was fallacious ; when
followed it led to overfeeding, an unbalanced ration,
unhealthy nutrition, and frequent attacks of vomit-
ing accompanied by acetonuria.

Precipitins for Egg Albumin in Stools. — Dr.

Clifford G. Grulee stated that the preparation of
the stools in this series of cases was the same as
that reported in a previous article. Egg white
rabbit serum of a titer of 1-40,000 was used. The
first series tabulated consisted of 100 stools from
twenty-one cases, with three positive reactions ; in
both instances the children received egg white in
the diet. The second series consisted of thirty-
three cases in which 242 stools gave five positives.
This series was carried out with an antiserum giv-
ing precipitants in a dilution of one to 60,000. In
this group some of the cases giving positive re-
actions had had no egg albumin in the diet. It
would seem from these results that egg albumin
was in nearly every instance completely broken
down by the digestive processes in infants and chil-
dren. This held good, not only for children and
older infants, but also where egg albumin was used
in small quantities for the newborn as well. There
was only one other possibility, and that was that
the egg albumin, instead of being broken down in
the process of digestion, was absorbed unchanged.
The writer did not feel that the specificity of the
precipitin reaction for egg albumin was to any
degree disproved by the fact that it was found to
be positive in stools where no egg had been present
in the diet. He was inclined to attribute such re-
actions to the complexity of the stool.

Role of Certain Anaerobes in the Intestinal
Flora of Infants. — Dr. Langley Porter, of San
Francisco, said that the information they had been
able to obtain since their last communication re-
ferred entirely to the group of intestinal toxemias
in which the abnormal stool bacteria were resistant
to dietetic measures usually adequate to produce
a change in the flora. In the course of this study
very rarely certain specialized fonns of colon
bacilli had been encountered. These were highly
facultative and extremely acid resistant, and so far
no effective method had been devised for overcom-

ing their interference when they were present in
the stools. On the other hand, investigation of the
evacuations of the majority of patients whose stools
showed a similar resistance to change in the floral
balance revealed the presence of an unusual number
of spore bearing organisms, most often anaerobes,
usually Welchii, which interfered by virtue of their
facultative powers. This facultative function en-
abled them to utilize any pabulum present. Because
of their power in the active stage to utilize carbo-
hydrate they were especially likely to interfere when
any attempt was made to shift a proteolytic flora
by feeding the patient a high sugar diet. However,
by the method suggested in this communication this
interference could be overcome and the disappear-
ance of these spore bearing organisms from the
stools insured. A diet limited in protein and rich
in carbohydrate would efifect this change.

Experiments to Determine the Persistence of
Extraneous Bacteria in the Gastrointestinal Tract
of Guineapigs as Influenced by Diet. — Dr. A.
Graeme Mitchell, of Philadelphia, stated that
thus far the proof of the implantation of organisms
in the intestinal tract rested upon incomplete evi-
dence. MetchnikofI based his claim of the im-
plantation of the Bulgarian bacillus upon experi-
ments carried out by some of his pupils and fol-
lowers. The work of the later investigators did
not substantiate the theory of implantation. The
present study was concerned only with the attempt
at implantation of an extraneous organism, the
Bacillus pyocyaneus, in the digestive tract of the
guineapig. The aim had been to study the prin-
ciples governing the implantation if such could be
accomplished. Bacillus pyocyaneus had several
advantageous characteristics for a study of this
kind. It was potentially pathogenic; it produced
poisonous substances in culture which in its patho-
genic relationship it assumes in various character ;
it could be fed in large numbers to the guinea-
pig without causing ill efifects ; above all it was easy
of recognition. With the exception of one experi-
ment in which the guineapigs received the organism
by stomach tube, the technic of the experiments was
as follows : The guineapigs were offered various
diets, and were fed the Bacillus pyocyaneus for
three days. At variable lengths of time after this
the animals were killed and culture made from the
heart blood, the stomach, the duodenum, the ileum,
the cecum, and the colon.

The conclusions deduced from these experiments
were that when guineapigs were fed on a diet of
oats, hay, bread, and greenstuff, Bacillus pyocyaneus
when fed disappeared from the gastrointestinal tract
within three days. When oatmeal was given as a
sole article of diet the Bacillus pyocyaneus had
been found at seven and nine days after the last
administration. The addition of a small amount of
greenstuff, or of a certain amount of butter to the
oatmeal diet, had apparently prolonged the period
of persistence of the bacterium. Pyocyaneus on
these slightly amplified diets had been found to
persist about two weeks with considerable regu-
larity. This increased persistence was probably
apparent Only. The animals on a strict oatmeal diet
did not live long enough to enable a complete experi-

January 8, 1921.]

LETTERS TO THE EDITORS.

87

ment to be carried beyond eight or ten days. The
organism could not be recovered in any case after
sixteen days. Judged by the amount of green color
produced in the culture the number of surviving
organisms became progressively less the longer the
interval following the cessation of its ingestion by
mouth. It was probable on the basis of these
experiments that there was an efifect of dietary
deficiency which consisted in the depression of a
normal mechanism controlling the implantation of
extraneous bacteria in the gastrointestinal tract.

The Urgent Need of Dietetic Reform and the
Duty of the Medical Profession Toward All the
Young of the Nation. — Dr. E. W. Saunders, of
St. Louis, drew a picture of the alarming physical
degeneracy in the rural and urban population, one
third of the youth of the nation being unfit for
military service ; immigrants from the Ghettos of
Europe rapidly degenerating in America, in spite
of better wages and more abundant food ; negroes
of the South physically unfit because of a diet of
commercial corn meal, and Italians failing on maca-
roni made from white flour. He asserted that the
first measure to combat the high cost of living was
to stop the denaturing of all foods by Federal law.
Existing pure food laws were aimed against sophis-
tication only. When these laws were passed, no one
knew that deprivation of essential food elements
contained in staple foods was , more deadly than
sophistication or substitution ; nor did any one
suspect that a diet of maintenance for the adult
might fail to sustain growth in the young. Imper-
fect and diseased teeth, fragile bones, weak muscles,
exhausted nervous systems, recurrent infections,
visceroptosis, stunted growth, inordinate appetite
for sweets and meat, craving for stimulants
and for excitement, inability for sustained effort,
perhaps imperfect development of the endocrine
glands, almost certainly a predisposition to can-
cer, all this train of evils could be laid to the
insane dietary of the American people of the
present day. The remedy was twofold, diffusion of
knowledge, and legislation.

Medical Supervision of the Boarded Out Child.

— Dr. Maynard Ladd, of Boston, described the
work of the Boston Dispensary, which was started
in cooperation with the Boston Children's Aid
Society and the Church Home Society, two of the
large child placing agencies, to demonstrate two
principles: 1. The value of expert continuous
supervision of children in the care of child placing
societies. 2. The value of utilizing for the purpose
the equipment and medical staff of an organized
dispensary, including specialties in all the chief
branches of medicine, in surgery, and in clinical and
X ray laboratories for modern medical diagnosis and
treatment. After describing the organization of the
preventive clinic. Dr. Ladd presented a statistical
study of 876 individual children. About five hun-
dred a year were cared for. Of these, fifteen per
cent, were sufficiently ill from one cause or another
to be admitted to the children's hospital wards,
which might be taken as a fair estimate of the hos-
pital requirements of such a group of children. A
little less than one third of the hospital admissions

were for necessary tonsillectomies or adcncctomies.
The low death rate of 1.1 per cent, undoubtedly
was influenced by the prompt detection of serious
cases of illness and the facilities provided for early
and, if necessary, prolonged hospital care. The
mortalit}^ statistics were interesting in the proof
they offered of the practicability of reducing the
death rate of a supervised group of children to a
point below that which was accepted as normal for
the community. There was a total of seventeen
deaths in three years among 1,531 cases, amounting
to one death a year for each one hundred children
under their care. Equally interesting were the
figures showing the effect of the special feeding
clinic in the nutritional development of the first and
second years. All the babies were fed on modifi-
cations of cow's milk prepared in the foster homes
and supervised by visiting nurses under medical
direction. Seven tenths of these gained in weight
considerably above the normal rate of the average
healthy infant, and three tenths only failed to reach
the normal rate by a small margin.

The conclusion justified from this experience was
that with proper organization and intelligent direc-
tion the boarded out baby, even though deprived
of its mother's milk, was a good medical risk, and
need not be deprived of its fair chance in life.
(To be concluded.)

'^ Exam-
filtering if necessary. The solution is ^hat did not
an autoclave. It should not be use^f o.steoplastic
fectly clear. We now employ icute osteomyelitis
solution. The optimurn doJilg on at the end of
twenty c. c. of this solutior has not been a single

96

NEUHOF AND HIRSHFELD:

SODIUM CITRATE INJECTIONS.

[New York
Medical Journal.

Admiuistratiou. — The solution is usually intro-
duced into a vein at the bend of the elbow through
a Fordyce needle with a twenty c. c. syringe. At
least ten minutes should be consumed for the injec-
tion of the drug. Otherwise it seems to us that
serious manifestations may possibl)- follow, for they
were observed in the experiments when citrate solu-
tions were rapidly introduced. Our custom is to
inject about two to three c. c, wait a few moments
to see if any discomfort is complained of, inject
another two to three c. c, and continue in this
manner until all the solution is introduced. In the
few instances in which we were in doubt as to the
advisability of continuing the introduction of the
citrate, we preferred stopping at a smaller dose
than the one planned. If any of the manifestations
to be described appear, we always await their dis-
appearance before the injection.

Since this paper was completed a death following
a citrate injection has occurred in another's hands.
The solution was not introduced according to our
technic. Under the impression that we may pos-
sibly not have laid sufficient emphasis upon the slow
and intermittent introduction of the solution as
ascribed above, the case is reported in detail. The
notes have been obtained through the courtesy of
Dr. A. A. Berg and Dr. E. Libman.

Case. — A woman, sixty-nine years old, was
operated upon for comrtion duct stone. Three days
after operation there was oozing from the wound,
after packings had been removed. As a prophy-
lactic measure against further bleeding a sodium
citrate injection was given. Sixteen c. c. of a
thirty per cent, solution (4.8 grams) were intro-
duced without pause within a five minute period.
Directly thereafter respirations ceased, and the
heart stopped beating several minutes later. At the
postmortem examination by Dr. E. Libman there
was no free blood found in the peritoneal cavity,
and no evidence of thrombosis or embolism. There
were adhesions from an old pericarditis, marked
sclerosis of the thoracic aorta, and a small carci-
noma of the stomach.

It is in a sense fortunate that the first death
following a sodium citrate injection should have
occurred in a case in which there was a fatal prog-
nosis from the gastric carcinoma, and it is signifi-
cant that a dose of the drug less than the maximal
dose accepted by others should have been followed
by death. But the object lesson is clear. We are
now no longer in the position of theorizing as to
the absolute necessity for the slow and intermittent
intravenous administration of sodium citrate, t^e
conclusion derived from our animal experiments.
The concrete case establishes the fact once and for
all that sodium citrate is a very dangerous drug
when injected intravenously w-ithout observing the
nrecautions we have taken and advised.
\. 'Tnife stations after injection of large doses of

cai-^i... citrate. — The following have been noted:

myocardu'^mbling of the lips, tingling sensations

and efficienc '^s, dizziness, nausea, a sense of

met shortly \. /'^.ss across the chest or abdomen.

vascular system. ^ no manifestations referable
D. — Systolic 140, g have been no untoward

pulse rate 64. Abnormal

aftereffects. No chills or elevation of temperature
were observed with a single exception. A patient
with a common duct stone and icterus had several
chills with fever during his short stay in the hos-
pital and suffered a chill with a rise in temperature
one hour after the citrate was given. No alteration
in blood pressure had been noted either during or
after the introduction of the citrate. Sodium citrate
is said to have a toxic effect on the kidneys, but
we have been unable to verify this clinically even
when very large doses were given. Up to the
present the drug has been administered in only one
patient suffering from a severe nephritis, and in
this instance no toxic manifestations were noted.
In short, we wish to emphasize the fact that no
evidences of toxicity were observed in any of the
hundred injections of large doses of sodium citrate
that we have given up to and including a dose of
fourteen grams.

Turning now to the effects of large doses of
sodium citrate administered intravenously in the
human being, we may say at once that they corre-
spond closely to those observed in our animal
experiments. A similar drop in coagulation time
occurs, the same change of the color of the venous
blood to a light arterial tint is usually seen, and in
all the cases of bleeding w^e have been able to
observe, the hemorrhage was controlled.

Change in coagulation time. — A typical curve of
coagulation time after the optimum dose of six
grams may be described as follows, the patient
having a coagulation time of ten minutes : Five
minutes after the injection the coagulation time
drops to seven minutes, ten minutes later it reaches
five minutes, in one half hour the coagulation time
is between two and three minutes. The peak is
reached some forty minutes after the injection, and
is sustained in the neighborhood of a two minute
coagulation time for an additional hour. The return
to the normal then begins, but this is much more
gradual than the rapid drop after the injection. In
six hours the coagulation time reaches five minutes.
Twelve hours after the injection it is still about
seven minutes. The return to the normal occurs
after a variable time ; in some instances the normal
is reached in twenty-four hours, in others not until
forty-eight hours or longer after the administration
of the drug. No subsequent changes in coagulation
time have been seen in observations taken two,
three, four, five and six days after injections. The
curve described is typical and figures closely
approximating those given have been obtained in
every instance in which such frequent observations
could be taken. Of noteworthy interest is the fact
that the coagulation time Avas shortened b}' citrate
injections to a similarly striking degree in patients
in which it was pathologically prolonged, especially
in jaundice. We have noted drops in coagulation
time from sixteen minutes before to two minutes
following the injection.

In the past few months almost all patients ad-
mitted to our surgical service received citrate injec-
tions and the pronounced change in coagulation time
was seen in nearly every instance, regardless of the
disease from which the patient was suffering. The
coagulation reaction following citrate administered

January 15, 1921.] NEUHOF .hXD HIRSHFELD: SODIUM CITRATE IXJECTIONS.

97

in optimum doses did not occur in a very few
patients. The condition for which these patients
came to the hospital offered no explanation for the
absence of the reaction although it is possibly sug-
gestive that three of them were suffering from
cirrhosis of the liver with jaundice. The absence
of any change in coagulation time following citrate
injection in these cases will only be accounted for
when the cause of the reaction is clearly understo6d.
The cause of the changes occurring after citrate
injection is unknown at the present time.

There are some cases in which a more prolonged
effect is desired than that obtained from a single
dose of citrate. We have attempted to sustain the
shortened coagulation time by repeating the dose
after twenty-four to thirty-six hours. As a result
the drop in coagulation time has been maintained
in some instances for several days, to return to the
normal in about a week ; in other cases the second
dose has had little or no additional effect. We
believe that the subcutaneous or possibly rectal
administration of sodium citrate will possibly prove
a better method when a slower and more sustained
result is desired and we are now engaged in study-
ing this question.

Change in the color of the blood. — The change in
the color of the venous blood to an arterial tint is
usually present within five minutes of the intro-
duction of the citrate solution. The return to the
normal hue of venous blood is noted as the coagula-
tion time again approaches that existing before the
injection. In the small group of cases in which the
coagulation reaction did not occur no change in the
color of the blood was noted and we therefore
regard this alteration in color as a characteristic
element in the reaction. The appearance is that
of venous blood that has been oxidized. We believe
that spectroscopic and other studies may demon-
strate that oxidization occurs as the result of the
citrate injections.

Consistency of the clot. — Concerning the clot that
forms in the test tube or at the mouth of an injured
vessel, there is every reason to believe that it is at
least as solid after citrate injections as normally. In
fact, we have gained the impression that a tougher
and more solid coagulum results from the intro-
duction of the citrate. The best demonstration of
the adequacy of the clot is the permanent cessation
of bleeding in the great majority of instances.
There was no evidence of intravascular clotting in
any of our experiments, and in none of the patients
to whom citrate was given was there any suggestion
of thrombosis or embolism.

Control of bleeding. — Our evidence of the strik-
ing and sometimes remarkable effects of large doses
of sodium citrate on bleeding in human beings rests
on purely clinical observations. It can truly be said
that bleeding would have ceased spontaneously in
some or perhaps many of the cases we have studied.
Up to the present time, however, bleeding has been
checked in every instance in which the citrate
injection has been given for that purpose. The best
proof that the cessation of hemorrhage is due to the
citrate injection is that bleeding regularly begins to
be controlled within fifteen minutes after the
administration of the drug.

Unless the underlying cause of a hemorrhage is
cared for, recurrence of bleeding may of course
take place, for the sodium citrate injection is only
employed for the immediate control of hemorrhage.
For example, a patient suffering from an incom-
plete abortion had been bleeding continuously for
several days ; bleeding stopped for twelve hours
after the injection, and then recurred and continued
until the uterus was emptied. There were three
cases in which hemorrhage controlled by sodium
citrate recurred after varying periods of time, to be
definitely controlled by a second dose of the drug.
These were one case of hemorrhage from a colos-
tomy wound for carcinoma of the rectum ; one of
hemorrhage from the abdominal wall after an ex-
ploratory laparotomy for an inoperable carcinoma
in a jaundiced patient, and one case of polycythemia
with bleeding from the gums after the extraction
of several teeth.

In all the remaining cases a single dose of sodium
citrate permanently controlled the hemorrhage.
These cases may be arranged in four groups:

Internal hemorrhage. — Blee(Jing was controlled
in cases of hematemesis, rupture of the liver, trau-
matic hemothorax, hemoptysis, and possibly in a
case of cerebral hemorrhage.

External hemorrhage. — These cases were varied.
They included lacerated wounds, hemorrhage from
the rectum, bleeding from raw areas left bare by
operation, and postoperative hemorrhages from the
rectum, gallbladder and prostatic beds.

Bleeding encountered at operation. — There were
a number of impressive examples at cranial, abdom-
inal, and other operations. A remarkable instance
was a case that proved to be cirrhosis of the liver
with icterus. The intravenous injection of citrate
was begun as the abdominal incision was made. In
exploring the undersurface of the liver an alarming
venous hemorrhage was started. Packings absolutely
failed to control this, and the bleeding point or area
could not be exposed. Without any other measure
being employed, the bleeding quite suddenly became
less and ceased soon after. The control of the
hemorrhage occurred fifteen to twenty minutes after
the introduction of the citrate. The excess blood
was sponged away and the operation continued
without further bleeding.

. Bleeding anticipated during or after operation.- —
In some cases it was difficult or impossible to deduce
any effect from the citrate injection because of the
necessary sponging at operation. In other instances
in which citrate was given the operative field was
manifestly less bloody than could have been ex-
pected. A striking example was a case of carcinoma
in which operation was performed recently by Dr.
Lilienthal. A T incision was made, splitting the
larynx and widely opening the pharynx transversely
to expose the neoplasm. Except for a few arteries
that were caught and ligated, the field was entirely
free from oozing. Other cases were instances of
jaundice with prolonged coagulation time. Exam-
ples of anticipated postoperative oozing that did not
occur after citrate injection are cases of osteoplastic
craniotomy and operations for acute osteomyelitis
in which oozing was still going on at the end of
operation. In fact, there has not been a single

98

Hi'S!K: PHENOIODINE.

[New York
Medical Journal.

instance of a postoperative hematoma in the wound
since citrate injections have been used as a routine
for all cases at the time of operation.

CONCLUSIONS.

1. The slow intravenous administration of large
doses of sodium citrate given intermittently over a
period of ten to fifteen minutes is nontoxic both
experimentally and in the human being. In the
latter, massive doses up to fourteen grams have
been given without any toxic manifestations.

2. The rapid intravenous administration of sodium
citrate is dangerous and may be fatal both experi-
mentally and in the human being.

3. The optimum dose for adults is six to eight
grams in a thirty per cent, solution and one to three
grams in greater dilution for children. Doses for
infants have not been determined.

4. All types of bleeding, internal as well as surgi-
cal, that have been encountered, have been controlled
by large doses of sodium citrate administered intra-
venously.

5. Large doses of sodium citrate have been suc-
cessively used to obviate hemorrhage in cases in
which bleeding was anticipated at operation.

6. This method of¥ers a large sphere of usefulness
in the treatment of bleeding, is a simple application,
and has proved both nontoxic and safe in our hands.

We wish to extend our thanks to Dr. Howard
Lilienthal for his courtesy and hearty cooperation
in this work.

REFERENCES.

1. Weil, R. : Jotintal A. M. A., 1915, 64, p. 425.

2. Ottenberg, R. : Proceedings of the Society of Ex-
peritnental Medicine and Biology, 1916, 13, p. 104.

3. KiNSELLA, R., and Brown, G. : Journal A. M. A.,
1920, 74, p. 1070.

1000 Park Avenue.

225 West Seventy-first Street.

PHENOIODINE IN PNEUMONIA, SEPTIC
INFECTIONS, AND ERYSIPELAS.
By J. A. HusiK, A. B., M. D.,

Brooklyn, N. Y.

This report is based on the work done by me
in my private practice and subjoined will be found
a presentation of cases by Dr. Herman Grad, at-
tending gynecologist at the Woman's Hospital,
New York, who at my request made use of the
treatment in patients sufifering from puerperal
sepsis, postoperative pneumonia, and erysipelas.

I wish to state at the outset that I have no new
theories to propound, that I lay no claim to the
discovery cf any specifics, and that I do not pretend
to understand fully how the coml)ination acts. All
I wish to present here is the clinical results follow-
ing the u.si of a combination of phenol and iodine
Avhen administered intramuscularly as observed by
my.iclf and others. It will not be out of the way,
however, to mention the fact that some scientific
investigation with phenoiodine solution was car-
ried out di ring the war at one of the naval stations
by Dr Wi'liam T. Moynan and here the fact was
brought to light that the injection of phenoiodine,
iatranniscularly, into the healthy human being
produced a marked leucocytosis. The leucocytosis

thus produced, however, was of temporary duration
lasting no longer than three hours. Subsequent
injections also served to bring about the same result
but the leucocytosis was then neither as marked
nor as lasting as after the first administration of the
drug. Based upon these findings. Dr. Moynan used
phenoiodine injections in the treatment of soldiers
and sailors during an outbreak of septic sore throat
and the results were described as highly satisfactory.
The infection was rapidly overcome and the patients
recovered within several days after the treatment
was begun. I hope a separate report at some future
date will be presented by Dr. Moynan.

The method of preparing the phenoiodine will
be given in detail at the end of this paper so as to
enable anyone to make the drug for himself. The
cost of the materials is so trifling as to be negligible.
The labor involved is quite considerable but will
be found no obstacle where the drug is really needed.
It is my hope that physicians and surgeons in charge
of large hospitals will give this form of therapeusis
a fair and thorough trial. For it is my conviction
that the therapeutic measure here advocated is of
the greatest value when used at the proper time
and in the proper case, that by its use a grave in-
fection will often be turned into a mild one, that
here and there the sacrifice of a limb will be avoided
and that occasionally life itself will be saved.

PNEUMONIA.

Case I. — Male, aged sixteen, schoolboy. Family
and previous history unimportant. .On March 2,
1920, late in the afternoon, the patient experienced
a severe chill which lasted ten minutes, and he com-
plained of headache. Home remedies were first
resorted to and an ordinary expectorant mixture
was prescribed the next day by his physician. The
patient continued to grow worse till the evening
of the 4th. At this point I was summoned to see
the patient. I found him in a condition of
delirium. He was mumbling incoherently to him-
self. The temperature was 104.4° F., pulse 128,
strong and bounding; respirations were short and
rapid, averaging 36. He was frequently coughing
up a thick, tenacious, mucopurulent and bloody
discharge. Physical examination showed consolida-
tion of the upper right lobe and the greater portion
of the lower left lobe.

Treatment was instituted and carried out as fol-
lows. Sinapism to chest and lower limbs and an
ice pack to the head ; digitol in ten minim doses
every three hours and a half ounce of whiskey in
four ounces of milk were administered every three
hours. Five c.c. of phenoiodine solution was now
administered intramuscularly and repeated in six
hours. At the end of twelve hours following the
first injection temperature fell to 100°F. ; pulse 106;
respiration 24. A third injection was now admin-
istered. The patient's general condition under-
went a most marked change within the twelve hours.
He was no longer delirious, his breathing was
deeper and free from pain, the cough lessened and
the bloody discharge disa]:)peared. From a condi-
tion pointing apparently to a fatal issue all signs
seemed to point to a speedy recovery. On
March 5th, at 8 p. m. the temperature rose to 100.5°

January 15, 1921.]

HiSlK: PHENOIODINE.

99

and the patient's general condition was not (|uite
as good as during the day. A fourth injection of
phenoiodine was now made. On the morning of
the 6th the patient's temperature fell to normal
apparently without the intervention of the usually
expected crisis. In short, thirty-six hours after the
first injection of phenoiodine and approximately
ninety-six hours after the initial chill the pneumonic
infection was overcome. All stimulation and in-
jections were now discontinued, an expectorant was
ordered and the patient made an uneventful
recovery.

Case II. — M. S., male, aged twenty-four; mar-
ried ; merchant by occupation. Family and previous
personal history have no bearing on the case. On
May 6, 1920, patient fell ill with the grippe. His
condition soon improved, but on the evening of May
9th he experienced a slight sensation of chilliness,
complained of headache and began to cough. The
patient remained in bed using all he knew in the way
of home remedies until I was summoned on May
Uth, late in the afternoon. At this time the
patient complained chiefly of his cough, pain in
the left side and a feeling of extreme weakness.
The cough was harsh and unproductive and no
bloody expectoration was in evidence. Tempera-
ture was 104°F., pulse 120 and respiration only 24.
However, physical examination revealed an area
of consolidation in the left lower lobe posteriorly,
which in the presence of the patient's history and
symptoms could not be taken for any other condi-
tion than that of a lobar pneumonia. Bronchial
breathing over the area involved was marked and
a distinct dull note over the area could easily be
delimited.

The treatment consisted in moderate stimulation
with whiskey and digitol. One injection of pheno-
iodine was administered at 5 p. m. and repeated at
12 p. m. On May 12th, at 9 a. m., the patient's
temperature was 100° F. ; pulse 100; respiration 22.
A third injection of phenoiodine was now admin-
istered and repeated at 8 p. m. The following morn-
ing the temperature dropped to 98° F. and pulse to
90. In this case, as in the first one, there was no
marked condition of crisis. The temperature came
down gradually. The treatment thereafter was
directed to alleviating the cough which continued
troublesome for about a week in the absence of any
fever or other symptoms of systemic infection. It
took about ten days for the pneumonic signs to dis-
appear completely from the lung. It would seem
from this that the administration of phenoiodine
intramuscularly in certain cases of pneumonia is
capable of destroying the active infection quite early
in the course of the disease process, although it takes
the usual time for the products of the infection to
become absorbed and eliminated from the system.

Case III. — Girl, aged four. Had always been
• well except for several attacks of bronchitis. For
a day or two immediately preceding this attack the
child had a slight cough which parents did not
regard as important. On January 12, 1917, patient
became suddenly very ill, complained of headache
and vomited once. The patient was first seen at
9 p. m. of the same day. At this time the child
looked critically ill. The temperature was 105.5°,

pulse rate was 160, and respirations 48. De-
lirium was not present but the patient was restless
and paid little attention to what was going on about
her. Plivftical examination revealed a small patch
over the right lower lobe where both anteriorly and
posteriorly soft, moist rales could be heard. On
auscultation bronchovesicular breathing could be
made out over the area involved and the percussion
note was slightly duller than over the rest of the
right lung. The left lung was free from disease.
The usual local and stimulant medication was
ordered and half the adult dose of phenoiodine was
administered into the gluteal muscles. This was
repeated after twelve hours. At the end of the
first twenty-four hour period following first injec-
tion temperature fell to 99° F., pulse to 108, and
respirations to 28. No further injections were
made. Ordinary stimulation was continued for
several days longer and expectorant treatment was
added. The child made a full recovery in a week.
There was no further rise in temperature. This
was the only case in which such marked and rapid
change had been observed as it is also the only one
in which treatment was begun so early in the course
of the disease.

Case IV. — This is a case of inhalation pneumonia.
An Italian laborer aged forty-four, painter by
occupation, fell down a scaffolding and sustained
a fracture of the nose. He received the usual treat-
ment by a surgeon at a hospital. Several days later
cough and pain developed in the right side of the
chest anteriorly. The pain was referred to the
sternum. His temperature soon rose to 103.6°,
pulse to 114, respirations 30. The cough was un-
productive at first and no blood was present.
Physical examination showed a small area of the
right lung presenting the usual signs of inflamma-
tion in this organ. Rales were present, with
modified vesicular breathing and a dull percussion
note. The -attending surgeon agreed that we were
dealing with an inhalation pneumonia. Treatment
was now begun and consisted in the ordinary form
of stimulation and phenoiodine injections were
administered once every eight hours. In all, five
injections were made. At the end of forty-eight
hours the patient's temperature, pulse, and respira-
tions came down to normal and he made a perfect
recovery without any further trouble from the
infection in his lung.

Case V. — This case is reported under pneumonia
for the reason that a pulmonary process developed
in both lungs during the course of a far graver
systemic condition. The patient was a middleaged
woman, single, high school teacher, weighed 240
pounds. Her family history was negative. The only
fact in her personal history that had any bearing
on the case was that she had been a frequent suf-
ferer from tonsillar infections and that she had had
a polyarthritis several times before the onset of the
present illness. On June 6, 1918, the patient suf-
fered from an attack of follicular tonsillitis from
which she rapidly recovered. She remained well
until the 26th, when suddenly her joints began to
swell. Every large joint in the body became in-
volved in the course of several days. On July 1st
there appeared a murmur over the mitral area, and

100

HUSIK: PHENOIODINE.

[New York
Medical Journal.

on July 3rd there developed a pulmonic infection
in both lungs. A blood culture made in this case
showed the streptococcus. The discharge from the
lungs showed both the streptococcus and the pneu-
mococcus. ■ The urine showed albumin, numerous
pus cells, and granular and hyaline casts. The
temperature varied between 103° and 106° F. ; pulse
range was between 120 and 140, and respirations
averaged 36.

Throtigh the courtesy of Dr. Ellen Lysaght, the
attending physician, I was called in to see the pa-
tient on the third day after the appearance of the
pneumonic lesions. It will be admitted that in the
presence of the findings stated above the condition
of the patient was most serious, the prognosis
grave and a fatal issue was the termination to be
expected. At this point, however, injections of
phenoiodine were commenced at intervals of four
hours. All antirheumatic treatment previously em-
ployed was discontinued ; stimulation was given
as before. After two days of treatment the patient
showed a great deal of improvement. The swell-
ings in the joints were markedly decreased, the
lung condition improved, the temperature range
fell to between 101° and 102° F. Her pulse and
respirations showed a marked change for the better.
The injections of phenoiodine were now reduced
to three daily. With the reduction in the frequency
of phenoiodine administration all the symptoms and
signs showed a tendency to become increased so that
more frequent injections had again to be resorted to.
In all, ninety-six injections were administered dur-
ing the course of the illness, which lasted six weeks.
By August 15th the patient's condition became nor-
mal. The infection was completely overcome. On
September 15th a pleurisy with effusion developed.
Thoracocentesis was now done and a quart of turbid
fluid removed from the chest but there was no pus.
She again made a rapid and complete recovery.
On January 1, 1919, the patient resumed her work
of teaching and has remained well since. The latest
report by Dr. Lysaght states that there is at present
only a slight cardiac murmur over the mitral area.

Other cases of pneumonia could be reported
from my own practice as well as from the work
of others who have employed the treatment, but
that would only be tedious repetition. One fact
should here be emphasized. In order to be
efficacious the treatment must be instituted as early
as possible in the course of the disease. When
started seventy-two hours after the onset of the
pneumonia it has little influence on the course of
the disease. I may also add that while no bacteri-
ological studies have been made except in the
instance mentioned above it is my opinion that
those pneimionias will be chiefly influenced by the
treatment in which the pus forming group of
bacteria are as much implicated in the production
of the toxemia as those that belong to the pneumo-
coccic group.

SEPTIC INFECTION.

Case. VI. — A laborer sustained an injury of the
hand. Three days later his arm began to swell.
In spite of the usual treatment applied to the local
wound the arm continued to grow worse. Six

days after the infliction of the wound the infected
arm grew to double the normal size, the patient
became septic and showed the usual septic tempera-
ture varying between 103° and 106°. The pulse
varied between 110 and 140. He had frequent and
profuse perspiration and was greatly prostrated.
A surgeon was consulted and he advised immediate
removal to the hospital for the purpose of amputa-
tion at the shoulder joint. The patient refused. At
this point treatment by phenoiodine injections was
commenced. One five c. c. ampoule was adminis-
tered every three hours for the first six doses. The
patient's condition had by now improved so
markedly that it was deemed safe to reduce the
frequency of the injection to once every six hours.
At the end of forty-eight hours the temperature
fell to 99°F., pulse to 85. The swelling was con-
siderably reduced. Prostration was no longer
present. Fifteen injections were administered in
all and the patient made a very good recovery
within a week after treatment was begun. Other
treatment consisted in stimulation with alcohol and
keeping up of the strength by liquid diet. A second
case practically identical in its details was treated
the same way and also with the same result.

erysipelas.

Case VII. — Male; aged thirty-one; school
teacher; single. Family and personal histories were
unimportant. On a Monday afternoon when
returning from school he began to feel an itching
and burning in his right foot. When the shoe was
removed the foot was found to be red, the
discoloration extending over the entire dorsum with
a sharp line of demarcation between the healthy
and diseased areas. The same evening the patient
was seen by me together with Dr. William T.
Moynan, who was then connected with the Post-
Graduate Hospital, New York. We both agreed
that the case was one of erysipelas. The tempera-
ture at 9 p. m. was 104°F. ; pulse 114. The patient,
however, did not look very ill. The treatment
consisted in the immediate administration of
phenoiodine followed by the local application of an
ichthyol dressing. No medication by mouth was
ordered. The following morning, 10 a. m., patient
felt much better. The itching and burning sub-
sided and the patient's temperature fell to 97.8°F. ;
pulse 70. A second and last administration of the
phenoiodine was now made and the ichthyol dress-
ing was continued for several days longer. No
other treatment was employed. The recovery was
complete as evidenced by the fact that on the fol-
lowing Saturday the patient was able to attend
a ball and to participate in the dancing.

Case VIII. — Female; Italian; aged thirty; mar-
ried ; had two children. February 2, 1919, the
patient began to complain of a burning sensation
in both cheeks. I was first summoned on the •
morning of February 4th. I found the patient quite
ill. Her temperature was 103.8°F. ; pulse 120.
She complained of headache and a feeling of
nausea. Did not vomit. Both cheeks by this time
showed considerable tumefaction and sharply de-
fined areas of redness covered both cheeks extend-
ing from the angle of the mouth almost to the ear.

January 15, 1921.1

GR.ID: PHENOIODINE.

101

and from the lower borders of the rami of tlie jaw
upward toward the zygoma. The erysipelatous
areas were peculiarly symmetrical. The diagnosis
of erysipelas was made and injections of pheno-
iodine were immediately instituted. One injection
was made on the fourth and repeated eight hours
later. On the morning of the 5th the patient was
found markedly improved in every way. Tume-
faction of the face was gone, pain and burning
disappeared and instead of the intense redness the
color of the cheeks became light pink. Temperature
and pulse were found to be normal. A simple tonic
was now prescribed and the patient was discharged.
She made a complete recovery.

Case IX. — Male, aged sixty-four, watchman.
Previous history unknown. This patient had a
deep and long incision made along the back of the
neck by his physician who mistook the condition
for a cellulitis. No pus was found. There was
an intense red area occupying the whole back of the
neck. There was a sharp demarcation line between
the diseased and healthy skin. The patient was
found to be very ill indeed. His temperature was
104°, pulse 120 and he was greatly prostrated. One
injection of phenoiodine was made and repeated
the next morning. At my second visit the patient
was very much improved. His temperature fell
to 99° and varied between that and 100° for several
days longer. Owing to the patient's age, his low
general vitality and the poor hygienic surroundings
the incision made was about six weeks in the
healing. Also because of these conditions an ab-
scess developed at the sight of injection. The pus
was readily evacuated by a small incision and healed
long before the incision in the neck closed up. In
the course of my experience extending over six
years this is the only instance where abscess forma-
tion had occurred. This was due in my opinion
to the patient's low state of vitality as well as to
the comparatively filthy surroundings in which pa-
tient lived.

UNTOWARD EFFECTS.

In a period of over six years during which I
have administered, conservatively speaking, be-
tween three and four thousand injections I have
seen no untoward effects save the case of abscess
mentioned. I have observed no reactions local or
general following the administration of the drug.
Some of the patients can taste the drug soon after
it has been administered. Others smell it in their
perspiration and in the urine. It can be readily
recovered from the urine and the feces. However,
the following was reported to me by others who
made use of the drug. In one case, in a woman
eighty-four years of age, who had been suffering for
three months from unresolved pneumonia, there
developed a suppression of the urine after the
exhibition of the drug. Another physician who had
used the drug reported the onset of an acute
nephritis. In this case we believe it was pure
coincidence. For in dozens of other instances in
which he had administered the drug he had observed
no ill effects whatever. In one of the cases reported
by me above the presence of albumin, pus and casts
in the urine did not contraindicate the use of the
drug. Ninety-six injections were administered in

that case and if the drug had the natural tendency
to bring on an acute nephritis it should have done
so in that case. But instead of that the kidney
condition cleared up together with the rest of the
infectious process. Dr. Herman Grad reports ab-
scess formation. However, the administration of
the drug was in these cases made by the nurses in
charge and good judgment is necessary in selecting
the site for injection where the same has to be
given every three or four hours. No abscess forma-
tion should occur with proper technic. In Dr.
Grad's patients, however, even the formation of
abscess will be no bar to the administration of the
drug for in them the question of saving the patient's
life is the immediately pressing one. I know of no
other instance of any ill effects. If there are any
they were not reported to me.

METHOD OF PREPARING THE DRUG.

The iodine to be used must be resublimed at
least several times. For each dose to be made four
grains of phenol and two grains of iodine are
measured off accurately and placed in an Ehrlen-
meyer flask. Five c.c. of a sterile normal saline
solution is now added for each dose to be made
and the whole is placed in a water bath from one
to two hours. This process results in the forma-
tion of the monoiodide of phenol plus a very small
quantity of the diiodide. The liquid is now allowed
to stand till it has cooled perfectly and the diiodide
has separated out and settled to the bottom. The
monoiodide solution is now poured off into a
sterile container and transferred to amber colored
ampoules of five c. c. capacity. These ampoules
must be kept in the dark in which manner the
product remains stable for at least six months.

Dr. Grad's report follows.

2559 Bedford Avenue.

PHENOIODINE IN PUERPERAL SEPSIS
AND POSTOPERATIVE PNEUMONIA.
By Herman .Grad, M. D.,
New York,

Attending Gynecologist to Woman's Hospital.

My attention was called to phenoiodine by Dr.
Husik, several years ago, and I have used it as a
therapeutic measure in several cases of puerperal
sepsis and in postoperative pneumonia with much
success. I feel that it should be used in every case
of puerperal sepsis. As a therapeutic measure it is
worthy of careful investigation by clinicians as well
as laboratory workers. I feel that it is a thera-
peutic measure of great value and has immense
possibilities for favorably influencing septic condi-
tions of the body.

My experience with phenoiodine is entirely a
clinical one. I have made no experiments with the
solution and know nothing of its physiological
action. All I can say is that it does favorably
influence septic processes in puerperal septicemia,
and that the clinical course of the disease is markedly
affected by the administration of the drug. In sep-
tic postoperative pneumonia it has a decidedly bene-
ficial effect which is often striking. The admin-
istration of a few doses of phenoiodine will cause

102

GRAD: PHENOIODINE.

[New York
Medical Journal.

a prompt amelioration of symptoms and will turn
a very distressing condition into a safe clinical
course of the disease. I have seen cases with most
alarming clinical symptoms, high temperatures,
severe pain in the chest with a distressing, dry,
harassing cough, benefited by a few doses of pheno-
iodine to a phenomenal degree. The symptoms
promptly subside, expectoration becomes profuse,
temperature and pain subside and convalescence
becomes established. It is the remedy par excel-
lence. I am so convinced of the positive therapeu-
tic action of phenoiodine in postoperative pneu-
monia that I have no hesitation in calling it a life
saving therapeutic measure.

In a case of erysipelas its action was most marked.
Without any local application the lymphangitis sub-
sided promptly. The tumefaction in the skin and
the pain promptly disappeared and in less than
forty-eight hours the disease was under control.
Of course one case proves little but Dr. Husik tells
me that the action of phenoiodine in erysipelas is
striking.

I beg to report the following cases :

Case I. — Mrs. R., aged thirty-one, para three, was
confined ten days previous to my consultation with
a low forceps operation. She sustained a moderate
degree of perineal laceration. On the third day a
sepsis appeared. There was a chill and the tem-
perature rose to 105° F. For the next six days the
temperature fluctuated between 100° and 105°.
There was pain in the lower abdomen and profuse
perspiration. Abdominal distention, coated tongue
and constipation were all present. The patient was
in a great state of apprehension having been told
that an operation was necessary to evacuate pus
from the pelvis. I was called in consultation on
this account. Pelvic examination showed uterus
and adnexa fixed by a solid exudate in the pelvis
with no point of fluctuation. I advised against
operative interference and recommended pheno-
iodine injections. Within three days after the first
injection the temperature showed a decided tend-
ency to subside and within a week the temperature
was normal and remained so. The patient received
thirty-six injections in all. The pelvic exudate
completely disappeared with no pus formation.
During the septic process a polyarthritis developed,
both knees, one wrist, and both sacroiliac joints
being involved. These joint involvements promptly
subsided the last one to disappear being the right
sacroiliac joint. The patient made a complete
recovery. My feeling in this case is that the pa-
tient would have recovered without the use of
phenoiodine but that her recovery would have been
a matter of months instead of weeks. That pheno-
iodine hastened her recovery and made her recovery
more complete without further complications of a
septic nature is beyond doubt.

The following case of puerperal sepsis was a
remarkable one and I feel that recovery was to
a very large measure due to the use of phenoiodine.
I say this because I wish to be conservative in my
statements. The truth of the matter is that clini-
cally the case was a fatal one of puerperal sepsis
and that phenoiodine was a life saving agent in this
instance.

Case II. — The patient was a young woman,
twenty-one years old, primipara, who was confined
six days before my consultation. She had been con-
fined in a tenement house. There had been a forceps
operation and the placenta was removed manually
as well as by curette. Two days later her tempera-
ture rose to 102° F., and she was again curetted.
The temperature now- went up to 106° and she had
severe rigors and vomiting. Her abdomen was
distended and she was not only profoundly septic
but she also showed signs of an active peritonitis.
When I saw the patient she presented the picture
of a fatal case of puerperal sepsis. Her tempera-
ture was 106° and she was delirious. Pelvic
examination showed a tender, subinvoluted uterus
with no exudate or masses. Her history, clinical
signs, her pulse and general appearance made so
unfavorable an impression on me that I gave a
fatal prognosis to the attending physician and a
guarded prognosis to the family. However, pheno-
iodine injections were advised and it was to be used
in five c.c. doses repeated every three hours. After
eight doses a marked change occurred in the clini-
cal course of the disease. The delirium disappeared,
peritonitis subsided, temperature and pulse were
lower, and in every way the patient was better.
Twenty-four doses in all were administered and
convalescence was established. Two large abscesses
developed at the site of injection. The pus was
evacuated and the patient made a complete recovery.

I have used phenoiodine in seven other cases of
puerperal sepsis, in every case with benefit to the
patient. It would be useless to detail their histories
as it would be a repetition of the two cases reported
above. Suffice it to say that my experience with
this therapeutic agent leads me to feel that it favor-
ably influences puerperal sepsis and should be used
in every case.

POSTOPERATIVE PXEUMOXIA.

I was greatly impressed with the therapeutic
value of phenoiodine in the following case of post-
operative pneumonia.

Case HI. — Mrs. A., aged twenty-nine, was oper-
ated on for a subacute appendicitis and retroversion
of the uterus. She was a short necked, fleshy wo-
man subject to bronchitis. At the time of the
operation there was no sign of pulmonary disturb-
ance. The operation was a comparatively short one,
but on the day following the anesthesia cough and
pain in the chest developed. Examination of the
chest showed a consolidated right lower lobe of the
lung. The temperature rose to 104° F., with a high
pulse, great pain in the chest, the cough was dis-
tressing. Hps blue, fingernails blue, with frequent
and embarrassing respiration. The patient appeared
very ill and it was distressing to note that none of
the usual therapeutic measures brought relief to the
patient. Twenty-four hours later the prognosis ap-
peared doubtful. The pneumonic process appeared
to have extended and the opposite lung showed
areas of involvement. The administration of pheno-
iodine was now started, five c. c. being administered
intramuscularly every three hours. After the third
dose the cough was less distressing, expectoration
was established, and the patient slept for an hour.

January 15, 1921.]

GEYSER: PHTHISIS PULMONALIS.

103

This was the first sleep she had had since the
operation without the use of morphine. Within
twelve hours after the first dose of phenoiodine
was administered a decided improvement had
occurred in the condition of the patient, and after
twenty- four hours a phenomenal improvement
was apparent. The therapeutic efifect of pheno-
iodine in this case was a revelation to me. Twenty-
four hours later all her symptoms — pain, cough,
temperature, rapid respiration, blue lips and nails —
had abated, and convalescence was established.

I have used phenoiodine solution, kindly supplied
by Dr. Husik, in five other cases of postoperative
pneumonia and in every case the therapeutic efifect
was definite and effective. I have no hesitation
in recommending this curative measure in every
case of pneumonia coming on after operation. I
feel sure that every surgeon will be interested be-
cause I know how promptly it acts and how benefi-
cial it is to the patient.

In two cases of infarct pneumonia following
operation, empyema developed in spite of the use
of phenoiodine, and resection of the ribs had to
be done. In both of these cases — one a gangrenous
appendix and the other a septic cholecystitis — the
pneumonia was most favorably influenced by the
phenoiodine. This was shown by the prompt
amelioration of cough, pain, rapid respiration and
physical signs. I feel sure that in the use of pheno-
iodine as recommended by Dr. Husik we have a
definite therapeutic measure that is as prompt as it
is efficacious in its therapeutic action.

40 East Forty-first Street.

PHTHISIS PULMONALIS.*

By Albert C. Geyser, M. D.,
New York.

The subject of phthisis pulmonalis is such a large
one and may be viewed from so many different
angles that it will be possible for me merely to call
attention to some of the more important and fre-
quently misinterpreted phases of the disease.
Neither will it be possible for me to introduce any-
thing new. All that I shall say is well known to
you, but I shall try to direct your attention to
phases of the disease which may have escaped your
attention heretofore. In fact, some of my state-
ments may seem almost heretic. Whether my con-
ception of this disease is right or wrong, I will
leave to your judgment. I myself am guided en-
tirely by the practical results obtained from thera-
peutic measures in harmony with my viewpoints.
cause.

Two factors are necessary for the existence of
this disease, namely, a suitable soil (lowered re-
sistance), and the specific seed (the germ). A suit-
able soil is furnished by anything which lowers the
physical resistance of the individual. The specific
germ is always with us. In ninety per cent, of
all human beings the germ is transmitted during
intrauterine life. The other ten per cent, are

*Delivered before the meeting of the American Association for
Medicophysical Research, October 7, 1920, Chicago, 111.

promptly infected during their first tew weeks of
independent existence.

This disease is a concomitant of civilization.
Only a few barbaric and semicivilized peoples are
still free from it. Such individuals are virgin soil
and become rapidly infected after contact with the
civilized. The average life of the Eskimo is two
and a half years after an attempt at becoming
civilized. In civilized communities the disease is
seldom or never propagated from the sick to the
healthy. The apparently healthy are already tuber-
culized. They have either been infected during
life in utcro or immediately thereafter; they have
recovered and are more or less immune ; they har-
bor within their systems the germs. Everybody is
a potential consumptive. Since the germs do not
thrive and multiply, they have not the disease in
fact, but are latent cases. A very few may become
entirely free from the germs, but are nevertheless
tuberculized. For confirmation I have only to point
to the fact that neither doctors, nurses, nor attend-
ants at sanatoria show any special percentage of
infection. There are few cases on record where
the husband or the wife have apparently infected
each other. In families with consumptive children,
only one or two showed the disease, yet in all these
cases there was unhindered contact day in and day
out.

BOVINE tuberculosis.

The acid fast bacillus found in cattle does not
cause phthisis in the human. If the fresh milk,
which may contain these bacilli, did cause the dis-
ease in the human, then the farmer's children would
be the first ones to suffer, because they drink the
fresh, warm milk. The dairy workers also would
show a high percentage of infection, owing to their
close and constant exposure. The children and
individuals of the city, far removed from the cattle,
living on pasteurized and sterilized milk, fall easy
victims to the disease. It is more likely that the
human phthisis patient by his expectoration infects
the cattle. After the germ has passed through an
existence in cattle, by attenuation it may have be-
come weakened in the same manner as a germ of
smallpox.

the physiological method of cure.
Up to 1882 it was well known that persons who
died from what was called phthisis or consumption
showed after autopsy that their lungs were studded
with small granules. These granules, or tubercles,
were an ever present accompaniment of this dis-
ease. It was thought that they were either the
result of or at least played an important part in the
disease process, hence the term tubercle disease or
tuberculosis. During the year of 1882, Koch, of
Berlin, discovered that every one of these tubercles
contained one or more acid fast bacilli ; that these
bacilli were surrounded first by a circular layer of
giant cells, then by a layer of ovoid cells, and lastly
by a third layer of round or leucocyte cells. En-
meshed within these last cells were usually some
lime salts. In a completely formed tubercle there
was not discovered a single trace of blood vessels,
showing that the centrally located bacilli were by
this means most effectually shut off from all out-

104

GEYSER: PHTHISIS PULMONALIS.

ORK

Medical Journal,

ward communication or escape. The entire tubercle,
however, might be expelled from the lungs the
same as any other foreign body, or it might remain
in situ as a bullet after having become encapsulated.
The fibrous capsule surrounding a bullet or the
formation of pus cells around a splinter are both
analogous processes to the formation of the tubercles
around the bacilli in the lung tissue.

These three processes are physiological and not
pathological. Tubercle formation, therefore, is a
conservative process ; it is Nature's method of
making the otherwise injurious bacillus practically
harmless. That such a process should not be inter-
fered with is selfevident; on the contrary, it is our
duty to assist Nature in her effort. All therapeutic
measures not in harmony with natural laws, while
they may appear highly scientific, are not' physio-
logical, therefore of questionable value.

For several centuries we have passed through
tuberculosis crusades. In some countries they have
taken on the appearance of actual persecutions of
the unfortunates and the destruction of their be-
longings. During later years these crusades have
donned the financial, political and educational garb.
After all the crusades, isolations, tuberculin injec-
tions, creosote inunction and inhalation, the percent-
age of the stricken is about the same. The death
rate has not changed and the building of sanatoria
goes on. All this appears as proof positive that
all of these measures have been tried and they have
been found wanting.

PHYSIOLOGICAL TREATMENT OF PHTHISIS.

Under no circumstances should a patient be sub-
jected to treatment based upon the x ray findings.
It is just as illogical to treat a clinically symptom
free patient for consumption because the x ray
shows lesions as it is to treat a patient simply
because he has a four plus Wassermann. Neither
the X ray plate of the lungs nor the four plus Was-
sermann of the blood has any significance in the
absence of clinical symptoms. I desire to call your
attention to a few very important points. Do not
treat the disease, but treat the patient. While this
rule applies to all diseases and all patients, it is
of especial value in consumption. Since every
human being is more or less tuberculized, and since
only one seventh of the entire race dies of con-
sumption, it follows that there must be all grades
of conditions between the two extremes. Not only
that, but the consumptive is ever hopeful of re-
covery and this psychic condition must be taken
advantage of to the fullest degree.

The treatment in general may be divided into
local and constitutional. It is to be understood
that every local treatment produces a constitutional
efifect and every constitutional measure affects the
local lesion.

General constitutional therapy. — Consumption is
a wasting disease ; it uses up tissue faster than the
patient can produce it; rest is therefore of para-
mount importance. To rest does not necessarily
mean being in bed. Whenever possible, and as a
rule it is always possible, the patient should spend
only the regular hours during the night in bed.
At all other times he should be fully dressed, though

lie may spend his time in a hammock or reclining
chair. Whenever possible he should take some
regular outdoor exercise from a mere fifteen minute
walk to playing games. Do not worry about the
fever; it will take care of itself — but more of this
later.

Outdoor air. — The best climate for a patient with
this disease is the one where he can spend twenty-
four hours of each day out of doors. It matters
little where this climate is found. As a general
proposition for those who can afford it, it is South
in the winter and North in the summer. The whole
secret of the outdoor treatment is to be found in
the fact that every person, sick or well, is sur-
rounded by a certain circular zon^ in which his
own emanations are continuously given off. A con-
sumptive gives off a certain odor, the reinhalation
of which is not conducive to his best interest. As
long as such a person is confined to a room, so long
is he obliged to undergo this reinhalation process ;
but while he is outdoors the air currents are con-
stantly removing these personal emanations and as
a result he breathes fresh air instead of his own
stale effluvia.

Altitude. — Some patients do well at the higher,
others at the lower altitudes ; some succumb at
both. It is not always easy to decide just where
certain patients should be sent, assuming that they
are to be sent away from home at all. As a general
proposition the physically strong and robust patient
with a good chest expansion will do well in the
higher altitudes, while the weak, shallow chested
individual does better at the sea level. There is yet
a third class of patients, those who can take a deep
breath but through force of habit never do. Such
a patient should be sent to a gradually increasing
altitude, while those who are perfectly willing but
cannot take a deep breath must live as near to the
sea level as possible. Now these are arbitrary state-
ments, but they are in perfect harmony with the
laws of physiolog3^ The barometric pressure at
the sea level is fifteen pounds to the square inch;
the higher we ascend into the mountainous regions,
the less is the air pressure. The more rarefied the
air becomes, the greater must be the effort at
breathing. For suitable cases such an effort be-
comes a lung gymnastic which must be of benefit
to the individual. When, therefore, the all too
common error is made of sending the weak, frail,
small chested individual to the mountains, he not
only fails to improve, but spends what little power
he may possess in a useless effort ; he literally wears
himself out trying to breathe sufficient oxygen to
maintain life. The average patient recovers best
at or near the same atmospheric and climatic condi-
tions where he or his parents were born. Such
conditions are natural to him ; he does not have
to acclimate himself.

Diet. — Consumption is a disease in which either
tissue metamorphosis is markedly increased or else
there is some interference with tissue assimilation.
It is a process of gradual wasting. Proteins are
the foodstuffs that maintain body weight and repair
tissue waste ; they are therefore indicated. Do not
attempt to fatten a patient ; a patient may gain in
weight, yet suffer from consumption. As a general

January 15, 1921.]

GEYSER: PHTHISIS PULMONALIS.

105

proposition allow each patient to select his own food,
especially those foods which the patient knows from
actual experience to have agreed best with him in
the past.

I would warn you against urging the use of raw-
eggs. Raw albumen is not only difficult to digest,
but is hkely to cause the patient to become "bilious."
There is, on the contrary, not the least objection
to the use of hard boiled eggs, providing they are
known to be reasonably fresh. Pure, rich milk, or
fresh cream and water, is a valuable asset. Do not
use pasteurized or sterilized milk if you can help it ;
such milk is lacking in vitamines. Since the physio-
logical process of forming tubercles requires lime
salts, there is no better or more natural way of
obtaining these than by having the patient take one
or two ounces of clam or oyster juice once or twice
a week.

Hygiene. — No matter how well a room may be
ventilated, it does not compare with outdoor air.
Every consumptive must be taught how to breathe
properly ; the breathing is too shallow in all of them.
Beside the usual bathing, a patient must take a
hot bath at least every other day. The bath must
produce free perspiration and be continued not less
than fifteen to thirty minutes. The hot. bath, at a
temperature of 107° F., is followed by a short cool-
ing bath at a temperature of 80° F. This prepares
the patient for a rub down or light massage just
before retiring.

Whether there exists constipation or not, the
rectal douche should be used at least on alternate
days. Do not fear the douching habit — there is
no more harm in regularly douching the rectum
than there is in regular mouth washings.

Local treatment. — The patient's own blood must
be caused to contain all the elements necessary for
a cure. When the hemoglobin percentage is below
eighty, the intravenous injection of cacodylate of
iron is the only remedy indicated. Five c. c. are
used once or twice a week until the blood improves.
At the present time there is only one way in which
the amount of blood can be increased through the
lung tissue, and that is by the use of diathermia.
It heats the entire pulmonary area through and
through ; it dilates the pulmonary capillary system,
thereby causing diapedesis of the leucocytes. The
fixed cells respond as a result of this by the forma-
tion of giant cells around the bacilli ; because of
the capillary dilatation and the increased diapedesis,
the wandering cells surround the giant cells, com-
pleting Nature's method by the creation of the all
necessary tubercle formation. The earthy material
from the clam and oyster broth furnishes the neces-
sary lime salt which is enmeshed in the third or
outer layer of each tubercle to make assurance
doubly sure that the escape and future damage by
the bacillus is made impossible.

Temperature. — Just a few words concerning the
fever. The irregular temperature is a curative
process ; it is the result of reaction to something
within the system. It is also evident that no matter
how high this temperature may be, it is inadequate
in amount. It may be adequate for the time being,
the temperature returning to normal or, from ex-

haustion, to subnormal. There may be a new pour-
ing out of that something which caused the first
reaction, so that we have a continuous attempt on
the part of the system to overcome or cure some-
thing. Taking this view of the rise and fall of the
patient's temperature, are we warranted in doing
anything . that would interfere with this curative
process ?

The answer is self evident. The patient's tem-
perature should be taken upon awakening in the
morning before getting up, again during the middle
of the day, and once more in the evening. These
three temperatures are then added together and
divided by three. If the quotient shows one or
two degrees above normal, that patient is in a fair
way to recovery ; if, however, the patient's daily
average temperature is below normal, the prognosis
is correspondingly bad. The temperature in con-
sumption may be too low; it is never too high.
This explains the efficacy of the diathermic phase
of the high frequency current. One must, how-
ever, be certain that the voltage is low while the
frequency and the amperage is correspondingly high.

Technic. — The high frequency machine which I
am about to demonstrate is of the telatherm type.
I have used this particular type for several years
now. It has undergone many changes, and I wish
to express my appreciation of the cheerful assist-
ance always offered by the manufacturer in carry-
ing out the various modifications as time and ex-
perience dictated. Today we have as a result a
high frequency apparatus of low voltage and un-
usually high frequency and a wide range of amper-
age. Either the diathermia machine, an earlier
model, or the telatherm, this latest type, answers our
purpose perfectly.

The ambulatory patient who comes to your office
should be treated at least every other day. A strip
of flexible metal four by eight inches is placed over
the spinal column and connected with one of the
binding posts. The other flexible tin, five by six
inches, is placed across the chest. Before applying
these electrodes they are moistened with soap lather
to insure better contact with the bare skin. The
current is turned on until a meter shows a reading
of 1500 milliamperes. The average time consumed
is thirty to forty-five minutes. If no untoward
symptoms occur after the second week, the current
is gradually increased to 2000 and later to 2500
milliamperes, the full output of the machine.
After the electrodes have been removed the parts
are sponged with cold water and the patient advised
to rest for one hour in the recumbent position.

All cases are divided into first, second and third
stages. First stage cases should show one hundred
per cent, cures ; that is, they should be converted
from open cases into latent ones. During the
second stage from sixty to eighty per cent, of closed
cases tnay confidently be expected ; while during the
third stage only occasionally a case does become
arrested, nearly all of the patients are made very
comfortable and their lives prolonged by many years.
While this short review of so large subject is en-
tirely inadequate, I hope that the discussion will
bring out many of the points necessarily omitted.
301 West Ninety- first Street.

106

GRAHAM-MULHALL: EXPERIENCES IN DRUG CONTROL.

[New York
Medical Journal.

EXPERIENCES IN NARCOTIC DRUG
CONTROL IN THE STATE
OF NEW YORK*

By Sara 'Graham-Muliiall,
New York,

First Deputy Commissioner, State of New York Department of
Narcotic Drug Control.

As adtnini-strator of the First District, which in-
cludes the Greater City of New York, where drug
addiction has so focussed that the city is called the
plague spot of the country, my task has been to
study intensively a hitherto insoluble problem and
to interpret and apply the law. My work may be
classified as both repressive and humanely construc-
tive. I have secured wholehearted cooperation and
support from physicians, manufacturers, whole-
salers, and druggists, in my campaign against the
misuse of drugs of addiction. The results achieved
are due in large measure to the success of these '
methods of cooperation. The repressive work has
grown out of the department's supervision of the
transactions in drugs by certain physicians, regis-
tered dealers and druggists, resulting in the detection
of irregularities, frauds and illegitimate practices.
Some idea of the vastness of this whole narcotic
problem may be gathered from the following num-
ber of certificates issued :

Physicians 10,364

Apothecaries 4,415

Wholesalers and manufacturers 286

Dentists 2,275

Veterinarians 342

Institutions and hospitals 336

MANUFACTURERS AND WHOLESALERS.

With the exception of medicine prescribed for
patients by physicians, all orders for narcotic drugs
involving the purchase or transfer of opium or
cocaine or their derivatives must be made on official
order blanks, serially numbered, which may be ob-
tained from the Department of Narcotic Drug Con-
trol by registered dealers or users, or by govern-
ment, public, or private hospitals. The only excep-
tions to this provision are, first, the permission to
sell certain exempt preparations without any formal
blanks, these preparations being remedies and medi-
cines containing not more than a specified small
amount of drug not considered dangerous and known
as the lawful quantity; second, the exemption of
such preparations as liniments and other ointments,
which, while containing more than the lawful quan-
tity, are in such form that the drug cannot be used
except for external purposes. A record must be'
kept, however, even of these preparations.

PAREGORIC NO LONGER EXEMPT.

Although heretofore exempt, a late ruling has
.'brought paregoric under control. At Bluefield,
'West Virginia, in May, 1919, a druggist was found
guilty of selling paregoric for other than medicinal
'purposes to an addict, through a second party, for
several months. The penalty was imprisonment for
two months or a fine of $200. Through this deci- sion the department has been enabled to figlit tlie paregoric habit in rural districts. We find that •Delivered before the Philadelphia County Medical Society on November 10, 1920. laudanum and paregoric are sold in large quantities by druggists and grocers in rural and suburban localities. The reports, whicli the law requires at present from physicians, manufacturers, wholesalers and druggists, include a record of all drugs received for local use or distribution, and all drugs sold within the state, with the amount, date, name and address of purchaser. These thousands of narcotic reports are carefully scrutinized, and when violations are found, department inspectors are immediately de- tailed on the case. This system of control by the department has resulted in reducing the amount of narcotics distributed by seventy-five per cent. In no division of control has greater vigilance to be exercised than in that which grants licenses to manufacturers and druggists. Reputable manu- facturers have from the beginning sent in carefully compiled reports which constitute valuable data for the department, and in all ways possible they have aided the department in the carrying out of the antinarcotic act. Since the department has exer- cised control over the manufacturers and druggists, there has been a great increase in the number of those seeking to enter the field of narcotic manu- facture. These applications are subjected to rigid investigation by the department. How unfit the majority of applicants are to be trusted with such commercial manufacture is indicated by the fact that only ten per cent, of those who apply are granted licenses. In a number of instances those applying have already been granted Federal licenses. In other instances applicants upon writing for licenses have given addresses that upon investigation are found do not exist. In one instance, an applicant who thus gave a fictitious address was finally arrested and found with$200,000 worth of illegally pro-
cured narcotics. He was tried and convicted.
Some of those who apply for licenses are gangsters,
and some former addicts. A common trick is to
secure a store or a loft in a busy building, pay,
rent in advance, and paint the windows so
heavily with green or black pigment as to render
them opaque. No furniture is put into the office
until a license is granted, indicating that they do
not intend to deal in the manufacture of drugs
generally, but merely to specialize on narcotics.
If the license is not granted, the applicants dis-
appear so that they cannot be traced.

There has been a great increase in the number of
applicants for druggists' licenses, showing that the
activities of the department have stimulated applica-
tions in this division. Great vigilance is exercised
over drug stores. While the majority of druggists
cooperate with the department, some' of them vio-
late different provisions of the law. These fill
doctors' prescriptions which are illegally made out;
others who cater to the narcotic trade have such a
tremendous rush of business that they do not
properly care for prescriptions. In one instance a
drug store, suspected by the department of illegal
practices, was raided, and thousands of prescrip-
tions were foimd in the cellar, so that the State and
Federal officials literally waded in them. It was
necessary to secure a number of bags and to engage

January 15, 1921.] GRAH AM -MU LU ALL : EXPERIENCES IN DRUG CONTROL.

107

a truck to take these to headquarters. Tlie drug-
gists encouraged their addict customers to loiter '
around their shops, either in the place itself or on
the adjacent corner. Drugs were the sole topic
of conversation among these loiterers, who smolced
incessantly. The department brought the matter tq
the attention of the druggists and requested them
not to permit their addict customers to remain in
the store or in the vicinity longer than to have their
prescriptions filled, and they were to go home before
administering it. The addicts were threatened with
arrest if they continued to make public nuisances
of themselves. Many druggists were warm in their
expression of appreciation of the department's vigi-
lance in this regard.

THE PHYSICIAN.

An erroneous opinion in regard to the physician
has been held by the public, that he is solely respon-
sible for the spread of addiction. Intensive study
of the narcotic situation shows unmistakably that
in ninety per cent, of the cases the addict under
thirty acquired the habit through bad association
and home environment, and the middleaged and
elderly become addicts through selfmedication.
Experience with thousands of addicts at the clinic,
through registration procedure, at hospitals and
with hospital releases, demonstrates that the nar-
cotic addict is a medical responsibility for ten days
— during the withdrawal period — after which he
becomes solely a sociological problem.

LEGITIMATE PRESCRIBING.

The only way the addict may obtain drugs legiti-
mately is through the instrumentality of the phy-
sician, who may either administer or dispense them
himself, or write a prescription for them. It is at
once evident that a very important power is given
to the physician and that a great deal depends on
the use he makes of this power. Most physicians
■ are exercising great care ; others are careless in pre-
scribing drugs, and some are known to be un-
scrupulous, using their professional Hcense as
middlemen in a nefarious practice in the enslave-
ment of addicts. It is because of these conditions
that the Department of Narcotic Drug Control has
had to exercise great vigilance in administering the
law. This is a very delicate problem, since the
general purpose of the law is not to add to the
burden of reputable physicians, but to check those
whose activities are questionable.

MISUSE OF THE OFFICIAL BLANK.

A woman arrives in New York with letters from
the physicians in her home city, in which it is
stated that she has a painful facial disease. The
woman comes under the notice of the department
when no fewer than four physicians, no one of
whom knew of the others prescribing, sent reports
and requests concerning her to the department. It
appears that when a physician, after prescribing,
explains to the woman that she must come under
the law and that he can treat her but once on an
' unofficial blank, she does not return to him, but
applies to another doctor, who innocently prescribes
for her and in turn appeals to the department in
her behalf, not knowing that she is a peripatetic
addict.

Here is an instance where a patient tried to take
an unfair advantage of the unofficial blank and thus
escape registration. Unfortunately for her, the
physicians whom she approached were law abiding
men, who refused to treat her the second time
without a certificate, and reported her to the depart-
ment.

Another case is that of a hospital orderly who
was registered as an addict with the department,
his dose being one grain a day. As his prescrij)-
tions ceased to come in, an investigation was made.
It was found that the man had gone to a commercial
prescribing doctor who knew him to be an addict
and from him he received prescriptions for four
grains on unofficial prescriptions.

The department has uncovered thousands of cases
of the misuse of the unofficial blank. Such viola-
tions of the narcotic act have been so flagrant and
difficult to unearth that a ruling to abolish the un-
official blank is the only possible method of control.

EXCESSIVE DOSES.

When I took office in April, 1919, prescriptions
of from forty to ninety grains of morphine or
heroine were frequent. The group of commercial
narcotic prescribing doctors aggregated in their pre-
scriptions in one month 1,760,000 grains of narcotic
drugs. The department early adopted the policy
of following up such prescriptions, and the pressure
it brought to bear has resulted in great reductions
in the amounts prescribed. It is now exceptional
to find prescriptions calling for niore than ten grains
of morphine. Cocaitie is restricted to a few grains
a month, and heroine has been practically eliminated.

In AJay, 1919, there were in my district sixty-five
commercial narcotic prescribing doctors. These
physicians controlled the narcotic situation to a
large extent. It was unfair that so small a group,
composed mainly of foreigners, should throw dis-
credit on the whole medical profession. No time
was lost in bringing pressure to bear on this group.
A striking example of the violation of the narcotic
act was furnished by one of the group. This popu-
lar narcotic practitioner left the upper sash of the
basement window lowered. Into this opening his
hundreds of patients daily tossed their registration
cards. These were gathered up by his wife and car-
ried to the doctor. On the morning of his arrest he
was found by the officers of the law, in bed, in an
upper story, with the registration cards of forty-five
of his patients, in which he was busily engaged
writing prescriptions for addicts whom he did not
see. It was the custom for his wife to return these
cards to the patients. Thus he was enabled to se-
cure a princely income with very little effort.

Previous to my taking office, one of these physi-
cians prescribed in one month 68,282 grains of he-
roine, 54,097 grains of morphine, 30,280 grains of
cocaine. This same physician after supervision by
the department prescribed 18,000 grains of mor-
phine in one month, no heroine and no cocaine. By
November, 1920, the number of commercial pre-
scribing doctors in my territory was reduced to
four, having over twenty-five patients, the highest
number prescribed for by any of the four being
a hundred.

108

GRAHAM-MULHALL: EXPERIENCES IN DRUG CONTROL.

[New York
Medical Journal.

A startling instance of a doctor prescribing a
grain a day for an infant shows a sinister phase of
careless prescribing. This infant was habitually left
on the sidewalk in a perambulator between 11 p. m.
and 3 a. m. When the mother was questioned, she
explained that she was obliged to leave the child on
the street as she earned her living by cleaning
saloons and drug stores after 11 p. ni. She could
not leave the infant at home because she asserted
that it was an addict and she administered the drug
to it at stated intervals. This she could not trust
anyone else to do. As the weather was warm, the
infant was more comfortable in the open air. I
wish to emphasize that this infant received a grain
j\ day on the prescription of a narcotic prescribing
physician. When the infant was placed in a hos-
pital under the observation of Dr. L. Emmet Holt,
the child showed no withdrawal symptoms. This
infant "was being drugged on the supposition that it
was an addict because its mother was an addict.

Another condition requiring control was the un-
expected result of an order issued July 31, 1919, by
the then commissioner of the Internal Revenue De-
partment, Daniel C. Roper. -This order to his sub-
ordinates stated that the vigorous enforcement of
the Harrison law must be carried out in such a man-
ner as not to 'produce unwarranted sufifering on the
part of the addicts. This was interpreted by the
commercial prescribing doctors as license to issue
emergency prescriptions.

An example of flagrant prescribing is furnished
by one physician, who wrote eight hundred emer-
gency prescriptions in one day. Another develop-
ment of this relaxation of the law was a flooding
of the department with demands for exemptions by
the commercial group from the rules and regula-
tions, until a total of eight thousand were received.
This entailed careful investigations and medical ex-
aminations, with the result that only five hundred
of the applicants were found to be entitled to ex-
emptions.

Further study of the situation revealed that the
addict was being supplied with drugs from many
sources ; from the prescriptions of physicians legiti-
mately and also in illegal ways. The first step in
the control of his drug supply was the establishment
of a narcotic clinic. The department also ordered
compulsory registration, appointing the commis-
sioner of health. Dr. Royal S. Copeland, its agent.
On July 14, 1919, registration went into ef¥ect un-
der his supervision. On and after that date every
addict was required to be registered. When he
presented himself at the clinic, he was physically
examined by a physician, after which he received a
registration card which contained his photograph,
his name, his address, his age, and his dose sheet.
Each time the doctor prescribed for an addict, he
was required to sign a designated blank space on the
dose sheet for that day, as was also the apothecary
when filling the prescription. It was hoped that the
addict would not receive more than one prescription
for that day because the next doctor or apothecary
would see that the space on the calendar dose sheet
for that day had already been signed, and therefore
would not vfolate the interpretation of the United
States Supreme Court's decision. Over 7,500 ad-

dicts were thus registered, which is undoubtedly
much fewer than the total number of addicts in the
city.

The dose sheets served to show, however, how
commercial prescribing doctors took advantage of
technicalities under the guise of the ambulatory
treatment. They accepted at face value the claim of
the addict as to the amount of drug he required, and
wrote the figures in such a way as to make forging
easy.

Apothecaries who were catering to this kind of
trade winked at the violations. Counterfeit dose
sheets soon made their appearance, and were forged
as to the amount of drug allowed. The extent of
the violations may be judged by the fact that the
-^department has a collection of 1,500 counterfeit
dose sheets, in which the same doctor prescribed for
the same addict twice a day on each of two such
dose sheets. The commercial prescribing group
signed their names illegibly, often with a mere wave
of the pen, making forging easy, and giving no
ground for prosecuting the apothecary who accepted
the prescription ofifered with such dose sheets.
Again and again the department realized what a
conspiracy ambulatory practice allowed.

Under this prevailing practice the addict is com-
monly treated by what is known as the ambulatory
method, by which the patient agrees to submit, or
pretends to submit, to the reduction of his dose
gradually by a slight amount while going about his
customary business, in the hope that eventually the
dose will be so small as to enable the addict to aban-
don it altogether without serious discomfort.

Can such a method succeed? It has been shown
that the craving for drugs is of the most pressing
and insistent sort; and that enforced abstinence
produces extreme agony. It has also been shown
that he cannot be trusted with any considerable
amount in his possession. Is it not contrary to all
reason and experience, therefore, to expect success
from a method by which the addict is asked to un-
dergo with fortitude and selfcontrol one of the most
critical stages in the cure of his habit?

Even those addicts who insist that they are de-
termined to rid themselves of the habit, after they
have had the usual dose, change in their mood, lose
determination and relapse when their supply seems
to be in danger. Many addicts have had the courage
to begin treatment under the reduction method, and
have placed themselves wholeheartedly under the
care of an honest physician. For a brief time they
have resisted temptation, and have held out against
violation of their pledge to rhe doctor while the dose
was being diminished by very slight amounts. But
sooner or later, the dose seemed inadequate or
reached too low a point ; they felt great pain and
complained of being ill. No restraint but their own
feeble will, weakened by years of addiction, has
stood as a barrier to their impulse to relieve their
sufifering and deceive the doctor. They have bought
drugs "on the street" or have gone to another doc-
tor for "treatment" thus doubling their dose. The
physician soon gets an inkling of this condition, and
it discourages his hopes of achieving a cure. The
drug addict thus learns to deceive.

The consensus of opinion among all those who

January 15, 1921.]

GRAHAM-MULHALL: EXPERIENCES IN DRUG CONTROL.

109

have given careful study to the problem of drug ad-
diction condemns this method, as is brought out
clearly in the report of Dr. E. Eliot Harris, chair-
man of the Special Committee on the Narcotic Sit-
uation in the United States, appointed by the Amer-
ican Medical Association. The large number of re-
peaters who went to the clinic and to penal institu-

^ tions gave strong support to this view which con-
demns the ambulatory method of treatment. The
clinic was organized for the humane purpose of sav-
ing the addict from the profiteering doctor and the
profiteering druggist and to prepare him for hospi-
talization. Addicts received their medicine at whole-
sale prices and they had every attention. They came
Fy thousands when they found that they could get
the drug for very little money and without doctors'

• . fees. The first day the clinic was opened, cocaine
was dispensed, but it was stopped on the second day,
no cocaine being again dispensed there. The chief
drugs sold were heroine and morphine, ninety per
cent, of the addicts who came to the clinic being
heroine users, who acquired the habit through bad
association. All classes attended the clinic — the un-
derworld, the criminal, respectable men and women,
including physicians, clergymen, nurses and actors.
The addict was started on the maximum dose of fif-
teen grains, regardless of whether he had formerly
received thirty or seventy grains (these being the
average doses prescribed for thousands of addicts
throughout the city). Thereafter the dose was reg-
ularly reduced in accordance with the decision of
the United States Supreme Court. Demoralization
set in and the addicts became discontented.

As the third step in control, a hospital at River-
side was opened and when the addicts reached the
irreducible minimum, they were compelled either to
go to the hospital or were refused further doses at
the clinic, the monthly dose sheet being then denied
them. At this period in the history of the clinic we
lost sight of thousands of addicts. The number of
prescriptions issued will give some idea of what the
work entailed, some days over two thousand pre-
scriptions being issued. As the dose became smaller,
the demoralization grew. The constant reduction of
• the dose incensed the addict and he resorted to petty
larceny — stole pocketbooks. fountain pens, any
small saleable object that he could lay his hands
upon. He also lied and forged in order to obtain
additional drug.

The majority of the addicts who patronized the
clinic were of the underworld type and the respect-
able men and women who were compelled to go
there through poverty were soon demoralized, their
addresses were secured and they were followed to
their homes. Peddlers openly plied their trade in
the clinic in spite of six supervising policemen.
When one peddler more daring than the others was
arrested, another immediately took his place. In the
course of time the addicts were shut out of the
lavatories and retiring rooms which had been as-
signed to them to selfadminister the drug, as they
grossly abused these privileges. The addicts then
resorted to an adjacent park where in the open air
and before groups of school children, they applied
the hypodermic needle and generally conducted
'themselves in an unseemly manner. The scenes be-

came so scandalous that petitions were sent to the
Governor of the State and to others calling for the
suppression of these demoralizing daily exhibitions
by the closing of the clinic.

Within a period of eleven months the clinic had
run its course. It had failed as a clearing house for
the hospital, had become a profitable market for
peddlers, and the socalled reduction method failed
to cure any addicts. It was only through the author-
ity the department imposed upon them, supple-
mented by moral suasion, that even so few as 2,800
of the 7,700 registered addicts were induced to go to
the hospital. The narcotic clinic stands out as an
enormously expensive and colossal failure. The
third step in attempted control was the hospital.

The experiment was made with a municipal hos-
pital, where the treatment was scientific and skill-
ful, which resulted in ideal conditions for the short-
term hospital experiment. The full treatment there
was for a period of six weeks only. Patients in all
stages of physical condition, undernourished, drug
saturated, highly nervous, or deadened by narcotics,
were received. These were each subjected to a pre-
liminary treatment suited to the needs of the indi-
vidual.

Quoting Dr. Braunlich in charge of this muni-
cipal hospital : "The marked abstinence symptoms
on withdrawal of the drug are selflimited to seven-
ty-two hours. After the drug has been withdrawn
and the addict has passed through the mild hyoscine
treatment, he finds himself in the convalescent build-
ing. Although he is much weakened, he is able to
be up and around, but because of his muscular
weakness and his sleeplessness, he is at his worst as
to his craving for the drug. This is the danger
period for the addict and it is during this time that
he needs the most careful watching and medica-
tion." At this hospital those in charge administered
at this period hypnotics such as bromides, veronal,
and chloral. Within another week the patient was
sent from the convalescent ward to the dormitory
building where he was given suitable work. He
received no more medicine of any kind except for
some intercurrent afifection.

Among all convalescent addicts a peculiar state
of mind exists, a craving for the drug which per-
sists even after its withdrawal. The tendency of
the mind is to revert to narcotics and this becomes
more pronounced if the former addict knows how
to get the drug or has hoped to get it. Dr. Braun-
lich states that if the patient has any hope of getting
the drug during the six weeks' period of treatment,
he will undoubtedly relapse into his old habit.

The addicts when discharged from the hospital
showed an average increase of from twenty-five to
forty pounds in weight. Peddlers and fellow ad-
dicts met the hospital discharges on the New York
boat landing and tempted them with an oflfer of free
drugs under the guise of good fellowship. Of those
who withstood the first onslaught, a percentage suc-
cumbed when they returned to their old neighbor-
hoods and met the boys and their former narcotic
physicians. We have demonstrated that the muni-
cipal short term hospital, although administering a
benign and effective cure, has been conceded by all
those in charge as lacking in the scientific feature of

110 ' GRAHAM-MULHALL: EXPER

classitication. Criminals, defectives, the tubercu-
lous, the moral and the immoral, and those whose
only weakness was drug addiction, were accepted
indiscriminately. This is a serious defect of the
short term hospital and is largely responsible for
the number who are buying drugs on the street.

When the department took office it found that
the addicts were generally despised and without
either officials or laymen to plead that they be treated
humanely. It was assumed without basis of fact
that the addict was a wilfully vicious creature who
refused to abandon his habit although he could do
so if he would'. Acting upon this theory the courts,
the police and the jail keepers treated him as a de-
> spicable creature who merited only severe treatment
and this was usually accorded him. Even the court
forms for voluntary commitments to hospitals were
couched in punitive terms. The department has
materially modified these hard conditions.

New York city was peculiar iji its form of drug
addiction, as over ninety per cent, of its drug users
were addicted to heroine, the most baneful, the most
powerful of habit forming drugs, and the most de-
trimental in its effect upon the user. It is cheap,
because it demands neither lay out nor hypodermic
svringe, and can be taken for some time without
disturbing the health ; it stops the craving without
diminishing the working capacity to a degree which
would prevent the earning of money to buy the
drug. It is sniffed through the nose on a quill, and
the addict can take heroine without fear of being
detected or being interfered with. This drug has
developed a distinct clas^ with a certain amount of
freemasonry and cooperation among themselves,
which is necessary to make it easy for users to pro-
cure heroine and also to safeguard one another in
the indulgence of a practice forbidden by law. The
majority of the heroine users were young_jnen
whose easy sociability developed into gangs. In
their leisure hours they flocked together in dance
halls, pool rooms, roller skating halls, and movies.
For some time the boys remain in good health and
possess a fair degree of intelligence. Because of
their youth they lack individual initiative, are imi-
tative and easily led, and fall into the habit easily,
the tragic part being, ignorantly. Once the habit is
festablished, interest is lost in work. The addicts
become late and irregular in their hours of work
and finally they throw up their positions. Many are '
good workmen, but they only work long enough to
**>procure money with which to buy the drug.
^ • On March 6, 1920. the department instituted *a
•' moral drive against the prescribing of heroine. The
' cooperation of doctors and druggists was asked
through every possible means of communication,
they being requested to substitute morphine for he-
roine all along the line. The response was cordial
and prompt, and within forty-eight hours from the
/time the signal was given to the first doctor, heroine
was taboo in the Greater City of New York. I am
in receipt of many letters from both physicians and
addicts warmly thanking me for the order. The
improvement reported is a lessening of nervousness,
improvement in appetite, and restful sleep, an expe-
rience many of them had not enjo\'ed for many
months.

ENCES IN DRUG CONTROL. ^A^^"^' Y""*"

Medical Journal.

Dr. B. reports: "It gives me pleasure to inform
yoU' that your ruling eliminating heroine has been a
blessing in disguise to many addicts. The first few
days were a nrghtmare to both the addict and the
physician ; however, as soon as the systems of the
addicts adapted themselves to the new drug (mor-
"phine) very few complained, in fact at least ten
openly expressed their happiness at the change. Do
not let anyone tell you that an addict cannot
let heroine alone, and don't let any one tell you that •
he will die. I think you made a glorious move in
doing what vou did (attack on heroine) March 8,
1920."

Now it is rare for the department to receive
a physician's prescription calling for even the small-
est amount of heroine. As you probably know, he-

. roine is being sent into China to a considerable ex-
tent, large amounts being exported from this coun-
try. The heroine habit there is taking the place of

^the far less dangerous vice of opium.

It is not always the perversion of the social in-
stincts alone that is responsible for the creation of
new addicts. Among those interested in such gangs
are the illicit peddler, the smuggler, and the traf-
ficker, whose commercial motives result in the en-
slavement of new victims. In its most vicious
]ihases, the power of dispensing the much prized
drug is one of the surest ways for a "Fagin" to hold
his pupils or a white slaver to maintain control over
his prey.

Peddlers, like drug addiction, flourish in centres
of large or congested population. True to the name,
the peddler has no store or permanent place where
he carries on his trade. He may take up his stand
at a certain street corner or in the middle of a block
for a day, possibly a week, after which he will move
to a position a mile or two away in the same city, or
even move to another city. The smuggled drug is
jiot, however, the peddler's sole source of supply.
He will often finance the drug addict. As an illus-
tration, the addict may be too poor to pay for a doc-
tor's prescription, or to pay the druggist for filling
it. The peddler will give him the necessary money,
it being agreed between them that when the addict
procures the dn;g he will divide ijt with the peddler.
A peddler who thus finances from twenty to fifty
drug addicts will obtain not only a fair supply of
the drug, but reap a material profit on his initial
outlay of money, for he sells the drug at a rate in
excess of that charged by the druggist, and he adul-
terates it in order to make it go further, the most
used substance for adulteration being sugar of milk,
or some other article sufficiently white to resemble
the drug. I have known of instances where the ad-
dict who had paid at the rate of a dollar a |j.rain
would get six tenths of a grain, and many more
instances where he would be sold nothing but pure
sugar of milk. I realize that this will naturally
cause the question to be asked, Why then does the
addict buy from the peddler? There are three
answers : The hesitation of having his addiction
known to the authorities, as it would be if treated
by a doctor or at a clinic; the inclination to satisfy
his craving by illegitimate means, and the fear of
having his dose reduced by the doctor or the clinic.

The speedy elimination of the narcotic peddler is

January 15, 1921.]

GRAHAM-MULHALL: EXPERIENCES IN, DRUG CONTROL.

Ill

the object of a plan I submitted to Commissioner
Enriglit, of the New York PoHce Department, a
plan which he accepted. It called for the creation
of a special narcotic corps with a criminologist, who
is also a physician, at the head. This corps supple-
ments the Federal, State and Municipal narcotic
agents and its special duties will be the detection
and arrest of illicit peddlers. The physician whom
I suggested as head of the corps had been for more
than a year in charge of the department's clinic,
where by special orders he was permitted to study
the conditions and histories of thousands of addicts,
also the policies and future plans of the department.
This cooperation between the State narcotic depart-
ment and the municipal police has resulted in a
vigorous campaign against the peddler. I have also
enlisted the cooperation of the State constabulary,
the chairman of which is Dr. Lewis Rutherford B.
Morris, for the outlying cities and towns of my dis-
trict. With these aggressive bodies continually on
their trail, the peddlers will soon realize that New
York is no longer an open town.

My appeal is now in behalf of 22,000 registered
narcotic addicts, together with unnumbered thou-
sands in this State, who are neglected and shunned
by the public. The following facts are pregnant
with meaning:

1. The addict cannot free himself.

2. He needs institutional custodial care to relieve
him permanently of his habit and to rebuild him
spiritually, mentally, and physically, so that he can
be returned to society an asset.

There is no gainsaying these statements. What
provision do the State and the city make to meet
adequately these desperate needs? New York city
closes its hospitals — Bellevue, Metropolitan, Kings
County, and the remaining hospital. Riverside, is
being run on a three weeks' schedule instead of one
of six weeks as heretofore. Its present capacity is
from fifteen to twenty-five, formerly a capacity for
800. The patients are now released when they are
psychologically and physically unprepared to be sent
back to their old environment and its temptations.
The results of this short term hospital emphasize
the fact that such limited treatment is a waste of
time and money.

The United States Government has fully recog-
nized that addiction is a country wide problem, but
it has only emphasized the punitive attributes of the
Harrison antinarcotic law rigidly enforced. This
is the crux of the whole situation. Due to these one
sided measures of attack, this problem has remained
unsolved because the Federal Government has thus
far failed to recognize that the humane attitude and
the law enforcement attitude are antagonistic and
nullify each other unless united, as they should be
in a great State institution for the proper custody,
care and cure of the addict. The same argument
holds good for the several States.

The initial step in this combination of effort is
the establishment of institutions where the addict
can be properly cared for on the institutional colony
plan, which admits of segregation of the several
classes and employment in the arts and crafts and
fanning. Such institutions should be under medical
direction.

Under a plan for commitment of drug addicts,
the State institutions can be used for the permanent
reclamation of these unfortunates. After the ad-
dict is taken oft' tlie drug, he will be placed under
the observation of experts for classification.

Class I : Those who suffer from a disease or
ailment recjuiring the use of narcotic drugs.

Class II : Addicts are those who use narcotic
drugs for the comfort they afford and solely by
reason of an acquired habit.

Class II may be subdivided into : a, correctional ;
b, mental defectives; c, social misfits; d, fortuitous
(occurring by chance).

For those who are found to be true defectives,
the State institution will not be the proper place, as
institutions are already in existence for the care of
mental defectives, where they are segregated and
made as useful as possible. Among the correctional
cases there will probably be worked out certain sub-
classes. Those who are true criminals will be sent
to other institutions. There will also be borderline
mental cases which can be industrially reclaimed and
returned to the world, if kept under the supervision
of a wise probation system. The true cases for this
colony life will be found among the social misfits,
who will find here their great chance to make the
start in life that they never had, under such direc-
tion as will assist them to find their proper place.
Such a life will also be of the greatest benefit to
those who are normal except for their drug addic-
tion.

The present is full of hope because we have
found, upon investigation and experiment, that the
drug addiction problem is soluble. To begin with,
the average age of the addicts is only twenty-four
years. We have brought the general public to a
realization of the extent and the menace of drug
addiction which it now knows transcends in serious-
ness the much discussed alcoholism, and this
awakened public opinion can be relied upon in the
future to support all worthy measures designed to
relieve this country of drug addiction. In spite of
the failures of the clinic and the short term hos-
pital, they have served the useful purpose of point-
ing the way to the only possible solution of drug
addiction, that is. the State narcotic institution on
the colony plan, for the rehabilitation of the addict,
physically, mentally, and morally. The department
is grateful to the members of the medical profes-
sion for the cooperation extended in the past, and
it looks forward to their cooperation and help in
the future.

Lithiasis of the Urinary Organs.— I. S. Kolb
(Urologic and Cutaneous Review, May, 1920)
concludes Aat there is no surgical procedure
fraught with more serious sequelje than litholapaxy.
It has its limited indications, but is more properly
controlled by contraindications. These latter are
very large calculi, very hard calculi, and infected
bladders. Small vesical stones in the absence of a
marked cystitis should be removed by crushing,
with a proviso that the operator be experienced and
skillful in the manipulation of the lithotrite ; other-
wise it is far better for the patient to have a supra-
pubic cystotomy.

112

MEDICAL SOCIAL SERVICE.

[New York
Medical Journal.

MEDICAL SOCIAL SERVICE IN
DISPENSARIES *

By the Public Health Committee of the New York
Academy of Medicine.

( Concluded from page 69.)

IX. AGENCIES REFERRING PATIENTS TO SOCIAL
SERVICE DEPARTMENTS.

Of the 675 cases studied, 170 came to the several
social service departments referred there by clinic
doctors ; 201 were sent from within the various in-
stitutions from sources other than clinic doctors,
and of these, forty-four, or 6.5 per cent, of the
entire group of new cases, were picked by the social
workers themselves; 175 came to the social service
through outside agencies. Of this division, schools,
settlements and relief societies referred eighty-one,
or 12 per cent, of all cases; private physicians re-
ferred twenty-four, or 3.6 per cent, of all cases,
while thirty-seven, or 5.5 per cent., came by per-
sonal application to the attention of the social ser-
vice departments. For 129, or over 19 per cent,
of the patients, the source of the original reference
was not designated. The large number of cases
regarding which no information is available as to
their initial direction indicates that the entries in
the records are not complete.

The clinic grouping of patients referred to the
social service departments shows that 22.7 per cent,
were under care in the children's clinics, 22.2 per
cent, in the tuberculosis clinics, 11.4 per cent, in
the cardiac clinics, 7.4 per cent, in the general
medical clinics, over five per cent, in the gyneco-
logical clinics, and practically the same percentage
in the poliomyelitis clinics ; twenty-two per cent,
were distributed among the other departments of
the institutions, and the clinic connection for the
remaining 4.1 per cent, of cases could not be ascer-
tained from the records.

X. PURPOSES FOR WHICH PATIENTS WERE SENT TO
THE SOCIAL SERVICE DEPARTMENTS.

An effort was made to obtain information from
the records as to the reasons and purposes for
referring patients to social service departments, in
order to determine what the functions of social serv-
ice are considered to be by those who refer the cases,
and by reason of such reference accordingly become.
We find that 52.7 per cent, of all the cases are
referred for what may be broadly termed medical
aid in the form of cHnical examinations (when
cases are referred from outside agencies), for
hospital, sanatorium or convalescent care, for
special treatment, for nursing, or for recreation
and rest. Eleven and one tenth per cent, were
referred for relief of one kind or another ; 7.6
per cent, were referred for instruction with regard
to the condition of the patient, the mode of
life, or the care of children; 7.9 per cent, were re-
ferred for an investigation, either with regard to
the home situation or the financial status of the
patient, or with regard to the occupation. Only

*This constitutes a part of the report on th- Dispensary Situation
in New York City by the Public Health Committee of the New
York Academy of Medicine, of which Dr. Charles L. Dana is chair-
man. Dr. James Alexander Miller is secretary, and E. H. Lewinski-
Corwin, Ph. D., is executive secretary.

0.9 per cent, were referred to have suitable employ-
ment found for them, 2.2 per cent, for family re-
adjustment to render treatment possible, 9.4 per
cent, for general supervision, and in 8.2 per cent,
of the cases reasons were not stated.

The greatest variety in the social service activities
is observed in application to patients of the pedi-
atric, tuberculosis and cardiac clinics. These three
departments also show the largest numbers of social
service cases. Taking the group of 356 patients
referred for medical aid, we find that 32.4 per cent,
of them were referred for a clinic examination,
over half being in the tuberculosis department;
twelve per cent, were in need of hospital care ; 13.7
per cent, needed convalescent care; eight per cent,
were in need of special treatment, and twenty-two
per cent, needed stimulation in order to make them
come back to the dispensary, the bulk being children
in the pediatric, poliomyelitis and cardiac cHnics.
A small number needed home nursing, and a few
patients were referred to the social service depart-
ments in order that examination in other clinics
might be obtained or that opportunities for rest or
recreation might be provided.

Among the seventy-five patients referred for
financial aid, 54.6 per cent, were in need of appa-
ratus for special treatment; 6.6 per cent, were in
need of funds to obtain the special diet prescribed,
and 38.6 per cent, needed general relief, belonging
economically to the substandard group. In fifty-one
cases referred for instruction, 23.5 per cent, needed
explanation of their condition, 33.3 per cent, instruc-
tion as to diet and general hygiene, and 43.1 per
cent, education in the care of children. Among
the group designated as "referred for investigation"
in thirty-eight instances was the home situation
specified as needing special attention. The other
fifteen cases were referred for investigation of
financial status to determine whether the patients
had claims on dispensary aid, all of them, however,
belonging to one institution where specialties are
treated.

To ascertain how clearly the cases were under-
stood by persons referring them, a table was pre-
pared comparing the purposes for referring cases
with the social service problem as it developed after
investigation had been made. Of the 356 cases
referred for medical care, in only 217, or about
sixty-one per cent., was medical care found to be
the chief problem. Of the remaining thirty-nine
per cent, of the cases, thirty-two per cent, needed
home instruction, 1.9 per cent, needed family re-
adjustment, 0.8 per cent, needed employment, and
4.3 per cent, needed financial assistance.

Similarly, among the seventy-five patients re-
ferred for financial assistance, fifty-four or seventy-
two per cent, required such help; 14.7 per cent,
needed medical aid, 2.7 per cent, needed employ-
ment, 1.3 per cent, needed family readjustment,
eight per cent, required home instruction, and in-
vestigation showed that in 1.3 per cent, of the cases
outside assistance was not desirable.

Among the patients referred for educational pur-
poses, 66.6 per cent, or thirty-four of the fifty-one
required that as their main aid. The remaining
thirty-three per cent, divided itself as follows: 5.9

January IS, 1921.]

MEDICAL SOCIAL SERVICE.

113

per cent., financial help; 13.7 per cent., hospital
care; 3.9 per cent., clinic care; two per cent., em-
ployment ; 3.9 per cent., family readjustment, and
in 3.9 per cent, investigation showed no problem
needing social care. From this it can be seen that
the workers freely change the plan of care • after
investigation has shown the case to be diflferent than
as at first supposed. In this respect medical social
work differs from home nursing. In the latter, the
nurse follows medical directions and is not free to
change the procedure without the sanction of the
doctor, while in the medical social work the i)erson
referring the case leaves the plan of action entirely
to the judgment of the worker.

XI. SELECTIOX OF PATIENT.

The discussion of the achievements and failures
of medical social work suggests the question as to
the point in dispensary routine at which the social
service department should begin to function. Should
it wait until the patient has made actual contact
with the clinic physician, or should it be the first
to receive him? With few exceptions the usual
practice is for the patient to come to the attention
of the social service department only after he has
passed through the clinic, and the facts about his
disease have been developed and medical treatment
prescribed. The first contact of the patient is with
the registrar, who may or may not be an agreeable
person. The patient then proceeds in his turn to
the Avaiting room, where he may wait as long as
an hour or more. Then his turn comes to go into
the clinic. There he is interrogated rapidly, his
examination made and treatment given . or pre-
scribed as quickly as possible, and he goes out,
probably without having had a real opportunity to
become adjusted to an unusual situation.

It is generally recognized that one of the most
important elements of successful functioning of the
dispensary is the establishment of proper relations
with the patient at the outset by giving him a proper
understanding of the dispensary's responsibility to
him and his responsibility to the dispensary, and
that this could properly come within the scope of
the social service department in the case of all new
admissions. A great deal of the now wasted effort
on the part of the physicians and the loss of time
and energy on the part of patients could be obviated
by humanizing the initial contact.

In one of the large special institutions of New
York, which has not a full fledged social service
department as yet, the experiment has been tried
out with a corps of visiting nurses and several
volunteers whose duty it is to interview patients
after they have registered. They take all the pre-
liminary history and the patient is given an oppor-
tunity to state his circumstances. All of this occurs
in a room sufficiently large to obviate the un-
pleasantness of telling one's story within the hear-
ing of fellow patients. Not only does this result
in securing better histories and in obtaining an
immediate understanding of the patient, but it
permits the patient to become adjusted to the dis-
pensary easily and gradually. Anyone who has
observed the smoothness with which this dispensary
operates cannot fail to appreciate the importance
of this method.

The financial information concerning the patient

called for by the representation card and the social
facts of the medical history could be elicited to
advantage by workers of the social service depart-
ment if arrangement were made to have every
patient pass first through the admission office of
the department. This information would ftirnish
the physicians with the important facts concerning
each patient and afford to the social service depart-
ment an opportunity of gauging the social problem
of the dispensary in its entirety, and to select for
its endeavor such cases as most need it or would be
most likely to profit by its assistance rather than
to leave entirely to the preoccupied physicians the
designation of cases needing investigation or guid-
ance. As has been shown above, physicians take
a markedly differing degree of interest in social
service work. Some refer many patients, others
very few or none. It is in justice to the patients
that a degree of freedom should be left to the
social service departments as to the selection of
cases, and also in justice to the department itself.
With a given personnel and a given amount of
funds only a certain amount of work can be done
effectively. As to that the department itself is
the best judge.

XII. RELATION OF SOCIAL SERVICE DEPARTMENT
TO SPECIAL CLINIC SERVICES.

The question of assignment of social workers to
special clinics is another important consideration.
Because of their magnitude, or because of the par-
ticular problems involved, certain departments, such
as tuberculosis, venereal diseases, or pediatrics, re-
quire the exclusive services of social workers. In
the determination of the assignment of social
workers, however, more is involved than the qtian-
tity of social service work needed in an individual
clinic.

If the dispensary is to be regarded as a training
ground for social workers, then the necessities
of such a training course must also be taken
into consideration and an opportunity should be
afforded for a working acquaintance with all fields
of dispensai^y work in which social service has
proved to be a most important factor. The deter-
mination of such fields should not be based, as is
often done, on the special interest or special de-
mands of the clinic physician. When a physician
has an appreciation of or interest in social work
he may, and often does, make demands upon the
social service department far in excess of its
capacity; if he is not interested in social work, even
though his clinic may offer a very fertile field for
it, he may make no demands upon the social service
department.

Determination of special clinic needs should
be based upon a comprehensive survey of the
entire field rather than upon the surface indica-
tions of the demands of clinic physicians, and such
a survey of the entire field is quite possible when
the social service department has the initial contact
with the patient, as has been suggested.

In the social service departments studied, the ten-
dency to assign special workers to certain clinics is
marked, for in thirteen of the fifteen dispensaries
in which children's clinics are maintained, social

114

LONDON LETTER.

[New York
Medical Journal.

service workers were found. In all of the dis-
pensaries having tuberculosis clinics, social service
workers are stationed in the clinics. Four of the
five dispensaries having cardiac clinics depend on
the assistance of a special social worker. In two
institutions special workers have charge of the
poliomyelitis work, and two general outpatient de-
partments have special prenatal workers. One of
the institutions has a worker devoting her time to
a vaginitis class. These workers are usually ex-
pected to help in the medical treatment as well as
to direct the social care of the patient.

XIII. A SOCIAL SERVICE CLEARING HOUSE.

Few dispensaries limit their services to patients
drawn from a definite territory. . It is well nigh
impossible to do so for a great many reasons, one
being the shifting of the patients. To deny a
patient admission to a dispensary which he had
formerly attended simply because he had moved to
a different section of the city is at times difficult;
l)Ut unquestionably there is a great deal of time lost
by social service departments in following up patients
who live at some distance from the dispensary.

The Maternity Centre Association established
several years ago, which has as its object the develop-
ment of standard equipment, practice and records
in the maternity clinics of the city, as well as the
development of an adequate centrally supervised
home visiting service, offers a suggestion which may
be of value particularly to the social service depart-
ments of dispensaries. Provided standard methods
and record forms could be adopted by dispensary
social service departments, such a central clearing
house for social service work could be extremely
valuable for the dispensaries in a given large district
in which there are several dispensaries, if not for
the city as a whole. The patient who is remote
from a particular dispensary could very readily be
referred to the attention of a social service depart-
ment near his home. Reports from one social
service department to another could readily be
exchanged through this central clearing house, or
referred directly from one department to another,
but the chief object of the clearing house would be
to provide the patient with social service ^id quickly
and economically, and in accordance with the de-
mands of medical treatment in the dispensary where
he receives attention.

It is suggested that such an experiment, although
fraught with difficulties, would be at least worth
trying. A number of hospital social service depart-
ments in a given area might pool their social serv-
ice work and cooperate with other outside agencies
interested in the social service problem. Central
control could be established under a competent direc-
tor for the entire district, in headquarters con-
veniently located within the district. All hospital
and dispensary social service workers as well as
workers from outside agencies would be placed
under the control of this district director, and all
demands for social service would pass through such
a director's hands, assignments for followup being
made as required. Reports of work done should
be returned to the office of the director and, when
approved, transmitted to the proper institution.

LONDON LETTER.
(From our own correspondent. I
The Ministry of Health Bill.

London, December 21, ig^o.

On, November 5th Dr. Addison, the Minister of
Health, moved the second reading of the Ministry
of Health Bill. Referring to the treatment of
mental disorders, he pointed out that during the war
a system had been set up whereby men suffering
from shell shock and affections of that kind, who
were mentally disordered for a short period, had
received mental hospital treatment, so that they
never became classed as lunatics, and thereby
escaped any disabilities which their mental state
might have brought upon them. The experience
of the war was clearly one of which use ought to
be made, and provision was made in Clause 10 of
the bill for the continuance of this form of treat-
ment, under very stringent safeguards for all cases
of this class. The bill provided that persons so
treated must be suffering from mental disorder
incipient in character and of recent origin. Treat-
ment in respect of any individual case would be
limited to six months. It was. necessary to erect
all possible safeguards so as to prevent any scandals,
such as the detention of people against their will
or anything of that kind. Some said the safeguards
were too stringent, but these points could be raised
in committee. The best course was to have a suc-
cessful experiment on a small scale without any
scandals and difficulties.

The minister now came to the proposal in the
bill which might involve an increased burden on
the rates. None of these he had so far discussed
would do so. The question of assisting the volun-
tary hospitals from the rates had 'aroused much
criticism. He had seen the headhne "Hospitals
on the Rates." That was not the proposal of the
bill. It was obvious that at no time of our history,
and certainly not up to the time of the experience
of the war, was it wise or practicable to ignore a
real and earnest public necessity. Nothing could
be more shortsighted. The fact was that up and
down the country the accommodation in voluntary
hospitals was unfortunately insufficient to meet
public needs. He thought everyone would agree
that anyone who suggested at the present time, if
by any means it could be avoided, that the voluntary
hospitals should come upon the rates, would be
either seriously irresponsible or worse.

The facts of the case were these : With the
assistance of the ofificers of the Ministry of Health
and those of the Red Cross, the financial position
of the hospitals for some years past was examined,
that is, of the voluntary hospitals. It appears that
during the five years 1913-18 there was a deficit
on the provincial hospitals in respect of excessive
expenditure over income of £1,300,000. So far
as London voluntary hospitals are concerned, the
deficit in round figxires amounted to £900,000.
During this time these hospitals received a number
of free legacies not earmarked for particular beds
and so on. He therefore thinks it is quite fair to
ask the hospitals in the present emergency to see
tliat these free legacies are u.sed to relieve ordinary

January 15, 1921.]

LONDON LETTER.

115

expenditure. If the free legacies of both London
and provincial hospitals were taken into account
they would balance the expenditure over the five
years mentioned. Unfortunately, however, some
of the voluntary hospitals were more fortunate than
others. With the increased cost of food, wages,
maintenance, and so on, unfortunately the expendi-
ture falling on voluntary hospitals had risen much
more than the income. There the discrepancy
between the two was greater than it had been.

Again, it had to be remembered that many of
those who had been accustomed to subscribe to the
voluntary hospitals had been very badly hit by the
war. For that reason, and because of taxation,
they had found it exceedingly difficult to maintain
their contributions and still less to increase them.
The class which was colloquially known as the
middle rich did not seem yet to have learned to
subscribe to voluntary hospitals in any extensive
way. Accordingly, the cooperation of the King-
Edward Hospital Fund was sought, and those
in charge of that fund had set aside out of their
accumulated reserve a sum of £250,000 to assist the
London hospitals. The King Edward Hospital Fund
being limited in its. operations to London, negotia-
tions with the National Relief Fund took place, and
that fund had set aside the magnificent sum of
£700,000 to help the voluntary hospitals.

There was a proposal in Clause 2 of the bill which
enabled local authorities, if they so desired, to
make voluntary contributions to hospitals, but in
this there was nothing new. So far as the volun-
tary hospitals were concerned, they were not
affected, except that an authority might make a
voluntary contribution. But the pressure on the
hospital accommodation of the country could not
in any case be met by the efiforts of the voluntary
hospitals. There were in the country 45,000 beds
in general and special hospitals, mostly maintained
by subscriptions, but there were 94,000 general
hospital beds under the poor law maintained out
of the rates. Thirty thousand poor law beds were
empty, while voluntary hospitals were crowded,
and had enormous waiting lists ; hospitals main-
tained out of the rates had a large number of empty
beds. He suggested that some practical scheme
should be devised to make use of good bed accom-
modation where it existed. There were two sets
of objections, the professional and that of the rate-
payer.

The hospital system is in a state of chaos.
Practically every institution, whether endowed or
not, is begging for money to carry on, while the
directors of some, notably of the London hospital
in the East End of the metropolis, state unreserv-
edly that unless large amounts are quickly forth-
coming their doors must be closed or, at least, a
part of the institution cannot continue its beneficent
or rather essential work. All are agreed that
nationalization or even municipalization of hospi-
tals is undesirable and the majority wish for a
continuation of the voluntary system. But if
sufficient funds are not forthcoming, how is such
a course possible? The Minister of Health states
that the King Edward Hospital Fund has given
$1,250,000 and that the National Relief Fund has donated$3,500,000 which will tide the voluntary
hospitals over their immediate difficulties.

After all, this is merely tinkering with the prob-
lem and does not reach the root. Sir George
Newman in his masterly work The Outlines of Pre-
ventive Medicine points out that the solution does
not lie in collecting money alone but in a thorough
reorganization of the entire hospital system of
Great Britain. However, while this statement is
absolutely true, what body is going to undertake this
reorganization and unification? The Ministry of
Health is unable to do so at the present time. This
department is choked by superabundance of serious
health problems. It has nolens volcns, to use an
American expression, "bitten off more than it can
chew." In the meantime the hospitals are going
from bad to worse. The voluntary system is im-
bedded in the hearts of the British public. Its
traditions are magnificent and if it could be ade-
quately supported it might be for the best for all
concerned to -maintain the system. There are many
who say that if those who ought to contribute to
the support of the hospitals according to their means
thus contributed all would be well. Yet people
cannot be pestered into giving, however subtle and
convincing the propaganda may be. The newly
rich, especially the individuals who have made for-
tunes out of the war, no doubt, as Dr. Addison said
in the House of Commons, have acquired the repu-
tation of expending large sums in ostentatious
display but have not acquired the habit of giving
to charity. It is to be hoped that their duties and
responsibilities, so far as charity is concerned, may
soon be impressed upon them. The working classes
who now earn three, four or five times more money
than they earned before the war and who receive
free treatment give with a niggardly hand to these
institutions from which they receive the most benefit.

Is there then a way out of the difficulty which
will avoid nationalization or municipalization and
placing more heavy burdens on the already over-
burdened ratepayers? There must be and one mode
has been suggested by some, namely, to introduce
the pay system or partial pay system. Let everyone
pay according to his or her means and while this
may not be a complete solution, it appears that it
will be going a long way in this direction. The
working classes can now afiford to pay and, in fact,
are in a better position to do so than the middle
classes who are mulcted in rates to an almost un-
believable extent. It seems that the general intro-
duction of a pay system would relieve the
immediate necessities of the hospitals, would do
away with a great deal of abuse of these institutions
by those who can afford to pay, would provide
efficient medical and surgical treatment to the poorer
ratepayers and would tend to self respect and inde-
pendence on the part of all who seek the services
of hospitals. The Ministry of Health cannot do
everything and with regard to the hospitals can
only give advice and assist to a limited extent. In
the last resort the salvation of the people in health
as in other directions, rests largely with the people
themselves. However, the Ministry of Health and
the medical profession generally can and should
point the way.

Editorial Notes and Comments

NEW YORK. MEDICAL JOURNAL

INCORPORATING THE

Philadelphia Medical Journal
and the Medical News

A Weekly Review of Medicine.

Address all communications to
A. R. ELLIOTT PUBLISHING COMPANY,
Publishers, 66 West Broadway, New York.

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NEW YORK, SATURDAY, JANUARY 15, 1921.

MEDICAL RESEARCH.

Scientific research and perhaps medical research
especially are greatly exercising the minds of mem-
bers of the medical profession and citizens in
general. The man in the street has a very hazy
idea of what medical research is and what it signi-
fies and if he were told that it was the foundation
stone of preventive medicine and, correctly inter-
preted and intelligently applied, led to health, he
would wonder what kind of nonsense he was being
told. The inner significance of medical research is
fully cotnprehended by the few only. The public
require education on the subject before the value of
medical research will be evident to the majority, and
therefore it seems essential that such education
should be freely profifered. If there is one man of
the English speaking world who is conscious of the
value of this form of research it is Sir Almroth
Wright, and consequently when he discourses on
the subject one may rely upon hearing something
well worth while.

On November 11, 1920, Sir Almroth Wright was
presented with the gold medal of the Royal
Society of Medicine and took the occasion to make
comments upon medical research and the conditions
indispensable to the achievement of new knowledge.
He said in part that the compilation of details was
within the power of every intellect ; the great need
in medicine at present was for more genetic
generalizations. For this a special type of intellect
was needed, and even then such generalizations
could only be arrived at slowly and as a result of

much study. Having arrived at a generalization
the next necessary step was to verify it. Four out
of every five generalizations believed and accepted
by men were wrong, and nine out of ten believed
by women. The scientific worker was the man
with a scientific imagination who afterward knew
how to verify. The man who made a genetic .sug-
gestion did not advance things unless he devi.sed a
means of testing it and had the skill to carry it out.
Experiment was the intellectual machinery for doing
this. The layman or quack could not do it. In
sliort, the man successful in medical research must
in the first instance possess imagination ; the pains-
taking plodder is unable to think out anything
original.

Bvit, in addition, the imaginative man engaged
in scientific research, medical or otherwise, should
be so trained that he can ascertain the value of his
ideas by the acid test of experiment. Sir Almroth
argued that, because the laboratory worker was
the sole person who could test his results directly
by experiment, he was in a better position than
anyone else, even the physician, who had to allow
time to elapse in order to learn results. From this
reasoning he drew several important conclusions.
If a hospital had no laboratory men at hand to
ascertain the effects of its treatment, advance could
scarcely be expected. Attached to every hospital
there should be a laboratory research stafif, whose
function it should be to test new things, to make
generalizations, and to extend knowledge by subse-
quent verification.

Stress was laid by the speaker on the need for
fully trained men to do laboratory work. Labora-
tories not attached to ho.spitals did not turn out good
work, as the stimulus of fresh inaterial from hos-
pitals was lacking. He insisted that men who
entered upon a career of research should have a
l^ermanent job, with an increasing salary. Lastly,
he urged that the only person who could direct men
to do useful research was one who knew the neces-
sary methods from having himself been engaged in
such . work. A surgeon or physician who had not
had this training had no rightful place on the direct-
ing stafif. The higher workers of the laboratory
stafif should be given a due share or voice in direct-
ing the policy. Assuredly the president of a re-
search organization should not be a busy politician
or any other layman ; he should be a person eminent
in science and whose energies were engaged in
connection with science.

There is little to cavil at in the exposition of

January IS, 1921.]

EDITORIAL ARTICLES.

117

what is required as to personnel and organization
of a medical research staff. Perhaps too great
emphasis is laid on the role of the laboratory worker
and too little on the part played by the clinician.
Surely laboratory tests by experiment are some-
times fallacious and, at any rate, clinical tests,
although they may be slow, are reliable. Of course,
the ideal plan is for the clinician and laboratory
man to work in harmonic conjunction and it cer-
tainly is essential, if the obscure features of disease
are to be traced to their innermost lairs, that a well
equipped, well staffed laboratory should be attached
to every large hospital. It is also obvious that with-
out imagination the research worker will never go
far, and, of course, he should be thoroughly trained.

No man should be a director of a laboratory un-
less he knows his work from alpha to omega, and
an active politician should be barred from holding
any such position. The public should be educated
to appreciate the benefits to be derived from
medical research work, and the work itself should
be carried on in the manner sketched by Sir
Almroth Wright. If this comes to pass, and there
is no reason why it should not, the results of
medical research work, the discovery of the causes
of disease, may ultimately banish the greater part
of the diseases which now oppress and handicap the
inhabitants of the world. However, if this end is
to be reached medical research must not be ham-
pered for lack of funds, and the community at large
must cooperate to aid its advancement.

WHAT EXERCISE IS BEST
"You need more exercise!" How often the ad-
vice is given without specification as to how, when,
where or under what conditions the exercise is to
be taken. And what, after all, do we mean by exer-
cise and what exercise is of most benefit?

By exercise, unspecified, we usually have in mind
the active, conscious, use of the voluntary muscles,
and often our thought goes no farther. These can-
not be made to work, however, without exercise of
the nervous machinery, and, accompanying and fol-
lowing the activity of the voluntary machinery,
there are sundry changes (exercise) of the invol-
untary nervous, muscular and glandular apparatus.
In fact, voluntary muscular exercise means an in-
creased activity of all structures of the body.

But the mere purposeless waving of arms, kick-
ing of legs or even so complicated a performance as
walking, after it can be done without conscious
effort, does not mean that the person is receiving the
maximum of benefit. It has even been asserted that
routine exercise done in a perfunctory fashion does
more harm than good. It is especially the mental

side of the human being that must be taken into ac-
count in exercise for health, for, unfortunately,
while the lower levels of the nervous mechanism may
be engaged in directing muscular movements, the
higher ones may be at work in such fashion as to
counteract the good results of the muscular move-
ments. The patient is early fatigued and wonders
why his benefit is so slight.

The degree of mental occupation thus becomes
a test of the value of exercise for purposes of
health. Mental work is always accompanied by
some, and often by great, activity of the other
mechanisms of the body, which does not show on
the surface. The driving of a motor car, which,
if not mental, is accompanied by continuous coor-
dinate use of muscles all over the body, and with
a fairly constant attention of the mental machine.
Boerhaave understood this vital principle for bene-
ficial exercise when he advised the obese gentleman
from Amsterdam, that, if he wished to be treated by
him, he must come to Leyden on foot. The wonder
and curiosity aroused by such an order which must
have filled the mind of the rich patient when it was
not absorbed in the passing scenery, made it pos-
sible for him to carry his unwieldy body the dis-
tance, and, by the time he had completed his journey,
the cure was well on the way to accomplishment and
was lasting. A wise American physician was in the
habit of advising his clients with little to do, to pur-
chase a dog and to take daily outings in its com-
pany. The dog was of course for the purpose of
objective mental absorption.

The work of teaching, primarily nervous exercise,
is accompanied by a vigorous activity of the whole
machine. The muscles become tense, the heart beat
quickens, and the blood pressure rises. When the
pupils respond in kind and there is no distraction
from the work in hand teaching can hardly be other
than healthful. Unfortunately these conditions are
rarely present, two things must be attended to at
once, introspection is mixed with circumspection,
and the former, as worry, is carried over for constant
nerve leakage in after school hours. Under such
conditions the exercise of teaching becomes weari-
some, wearing and anything but beneficial, and the
only help in the case is to seek other occupation.
Exercise to be most beneficial must, then, be some-
thing more than mere calisthenics — something more
essential than mere muscular contractions and re-
laxations but should be some occupation, it matters
little what, in which the machine works as a whole
and with self forgetfulness. It is the mental side
which must be looked to first in prescribing exercise,
the mere muscular performance is of minor import-
ance, save that the latter should be fitted to the
strength and endurance of the exerciser.

118

EDITORIAL ARTICLES.

[New York
Medical Journal.

HEMATEMESIS AND VARICOSE VEINS
OF THE ESOPHAGUS.

Hematemesis is one of the principal symptoms in
certain diseases of the esophagus, stomach and duo-
denum, gastric ulcer being probably the most fre-
quent cause of the vomiting of blood. In ulcer of
the stomach this is preceded by nausea, while in
diseases of the esophagus the blood is vomited with-
out any preceding malaise. Duodenal ulcer may
give rise to hematemesis, but it is less common in
this affection than melena. During the evolution of
hepatic cirrhosis blood may be vomited, and this is
usually attributed to varicose veins of the esophagus,
but even when abundant and repeated the hema-
temesis may take place without the existence of
varicose veins of the esophagus, or if these do exist,
without ulceration. On the other hand, varicose
veins of the esophagus may develop without cirr-
hosis of the liver. Lastly, in hemophilia very severe
vomiting of blood may occur.

Hematemesis ofifers two distinct types, according
to whether the blood has been retained in the
stomach or is expelled at once. In the latter case it
is fluid or coagulated, but easily recognized as blood.
When it has been retained in the stomach it under-
goes digestive changes, and is vomited in the form
of small, blackish lumps. The black transformation
of blood in the stomach depends upon two factors,
namely, the amount of blood and the length of time
it has been in contact with the gastric juice. A
severe hematemesis gives rise to all the symptoms
met with in profuse hemorrhage, but slight, re-
peated hematemesis may lead to anemia.

The esophagus has a rich supply of veins, arteries
and lymphatics, and is innervated by the pneumo-
gastric and a few branches of the sympathetic. The
venous network receives its blood from the portal
vein, which from its anastomoses communicates
with the caval system. From the viewpoint of the
etiology of esophageal varices, some observers adopt
the same classification as for hemorrhoids, namely,
those having a mechanical cause, and secondly, the
constitutional or idiopathic type. In the first class,
the process may be due to temporary compression,
while permanent compression results from diseases
of the portal vein, or hepatic processes, particularly
cirrhosis, dilatation of the stomach, and lastly,
diseases of the spleen and heart, especially lesions of
the mitral valves, and esophagitis. Esophagitis,
whether acute or chronic, is more prone to occur at
the upper portion of the tube, the lower and middle
portions being less commonly involved. Ulcers de-
velop and may occasionally give rise to purulent
foci, the former often contributing to rupture of
the varicose veins present.

Varicose veins of the idiopathic type are due to
rather complex causes, such as climate or plethora,
while heredity plays a considerable part in the
etiology. When the cause of the varix is temporary,
as in pregnancy, phenomena of congestion appear,
but are usually mild, and after labor has taken place
the process disappears. When the cause is a per-
manent one, the congestion is likewise, although a
spontaneous cure is not impossible. On the other
hand, idiopathic varix is marked by intense con-
gestive phenomena, with or without hemorrhage,
and, if this is repeated frequently, anemia and
digestive and cardiovascular disturbances occur.

The outcome of the process may be recovery, but
usually it becomes chronic, and the evolution is sub-
ordinated to the occurrence of complications. Death
may occur from hemorrhage or some intercurrent
affection.

PHYSICIAN AUTHORS: DR. JAMES BALL
NAYLOR.

One of President-elect Harding's closest per-
sonal friends is Dr. James Ball Naylor, of Malta,
Ohio, who, in addition to being a practising physi-
cian, also has been for the past seven years a special
editorial writer on the staff of Senator Harding's
newspaper, the Marion (Ohio) Star, and is an
author of nationwide reputation, with seven novels,
three books for children, one book for boys, and
four books of verse to his credit — besides many
short stories, special articles, and campaign songs.

Of course, Dr. Naylor is in politics, too. It is next
to impossible for an Ohioan to keep out of politics.
"I play the game of politics because I like it," says
Dr. Naylor, "not with the expectation of reforming
the people, and not because of the hope of reward.
I aspire to no seat among the mighty. I simply
desire to live my own life, in my own way, to my
own satisfaction. If I can do a little good every
day in so doing — well, so much the better." It was
through politics that he and Senator Harding became
acquainted, during the campaign of 1910 when
Harding ran for Governor of Ohio and Dr. Naylor
was the Republican candidate for State Senator of
his home district. Both were defeated. During
the course of the campaign they spoke from the
same platform on numerous occasions and a warm
friendship sprang up betwen them that has con-
tinued ever since. When Senator Harding was
elected to the United States Senate in 1914 he chose
Dr. Naylor to take his place as the writer of leaders
for the Star. Dr. Naylor coupled this work with
his medical practice and continued to reside in
Malta, where he has practised ever since he got his
medical degree at Starling Medical College, in

January 15, 19-' I.)

EDITORIAL ARTICLES.

119

Columbus, Ohio, in 1886. Malta is but a few miles
from Pennsville, Ohio, where Dr. Naylor was born
on October 4, 1860, and so great is his affection
for the quiet little Ohio village, and so strong his
dislike of city life — even such mild city life as is
aflforded in Marion — that no temptations have suc-
ceeded in weaning him away from it. "1 like the
country; I dislike the city," says Dr. Naylor. "I've
spent days in New York, Boston, Chicago, Cleve-
land, Columbus, and other cities, but I've always
been glad to get away from them and back to the
rural solitudes."

It may readily be guessed that Dr. Naylc^r took
a very active 'part in the recent campaign which
resulted in the Harding landslide. He has taken
pan in every campaign in Ohio for the past thirty
years, but it was natural that in this last campaign,
with a personal friend running for the Presidency,
his political enthusiasm should be keyed up to its
maximum pitch. Paraphrasing the old adage, ap-
parently Dr. Naylor's motto is, "Let me write the
songs of a campaign and I care not who makes the
speeches," for he has written probably more cam-
paign songs than any other living man, and they
have been first class ones, too. If there are any
who doubt Dr. Naylor's skill along this line, it is
only necessary that they peruse the pages of the
Republican Campaign Songbook for 1920, issued
by the Ohio State Republican Executive Committee,
and be convinced. The book is largely the work of
Dr. Naylor, and gives ample proof of his consum-
mate cleverness in such work. They are rollicking
songs, for the most part written to fit the tunes of
Casey Jones, A Hot Time in the Old Tozvn, Long-
Boy, and such like droll ditties, full of irony and
ridicule designed to make a laughing stock of the
opposition and to inspire enthusiasm and faith in the
ticket and cause espoused. Some are in a more
sober vein, however, as if to keep a proper emotional
balance and adjustment, and carry such staid airs
as those of America and The Battle Hymn of -the
Republic. But whether blithesome or serious, Nay-
lor's campaign songs always have a touch of inspired
fervor about them, and this was particularly true
of his efiforts during the recent campaign.

Naylor's four volumes of poetry show him to be
capable of some very gracefully turned verse full
of homespun optimism, lively humor, and love of
his fellowman. He sings of those homely themes
that are close to the heart of that class of reader
who knows what he likes and likes it so well that
he clips it out and carries it around in his pocket,
or else pastes it in a scrapbook. They are poems
of simple appeal, of the James Whitcomb Riley
type, but with less emphasis on the uncouth. In

them Naylor touches deftly upon all those humble
little phases of life which go to make up the exist-
ence of the commonalty of the rural sections of the
Middle West. They are the verses of a natural
poet whose heart is flowing over with sung, and
they are a refreshing relief from the stilted erudi-
tion that marks so much of the poetical product of
today. Naylor's novels include The Sign of the
Prophet, The Kentiickian, a vividly told story of
Ohio life in Civil War times ; The Misadventures
of Marjory, the story of a young, vivacious and
audacious heroine of the desperately willful type;
Under Mad Anthony's Banner, a tale of the War
of 1812; TJie Scalazvags, hi the Days of St. Clair,
a Middle West historical novel, and The Cabin in
the Big IP'oods, a stor}' of pioneer Ohio life.

Dr. Naylor was educated in the public schools of
Ohio and at Marietta College, Ohio, after which he
attended Starling Medical College. "I'm sixty years
old according to the records, but I'm 600 years old
when it comes to varied experiences, and I'm 6,000
years old when I come to count the mistakes I've
made and the blunders I've committed," he says.
"I'm a Yank, not a cosmopolite; an American, not
a world citizen. I'm at home where my heart is,
not where my hat's off^. And my creed is :

When my country's in the right
I'll defend her with my might ;
When my country's in the wrong
I'll help to set her right ere long.
But whether right, or whether wrong,
I've just one love — I've just one song:
My country !

"I like dogs and children. I'm the father of six
children, all living and grown, and the grandfather
of five. Yet I can still live, and love and laugh.
I write prose as a duty or a task ; I write verse for
the joy of it. When I write prose I live on Grub
Street ; when I write verse I dwell in Paradise
Alley."

Except for his editorials, however, Dr. Naylor is
not writing a great deal these days. The editorials,
his medical practice, and the office of District Health
Commissioner of Morgan County, Ohio, leave him
little time for anything else.

NASAL STASIS.

Lord Chesterfield, whose good manners none may
doubt, told his son not to use his handkerchief at
table, but to rise and go to a window, turning his
back to the company. He does not say anything
about that irritating, persistent, discordant habit of
sniffing. It begins at an early age, sometimes
through nonprovision of a handkerchief, or ignor-
ance of how to use it, though there is the sniffs of
laziness, making it a substitute for what is termed

120

XEli'S ITEMS.

[New York
Medical Journal.

— a good blow. The siiifif of contempt or incredulity
is not due to nasal stasis and no handkerchief, be it
ever so large, or fine, or perfumed, will spare friends
the exasperation of hearing it.

Children in their desire to keep their airways
free sniff away any excess of discharge away from
the main currents. The semifluid mass in the nos-
trils is constantly drawn in and is, finally, difficult
to remove. Perpetual sniffing, with no wholesome
outward blowing, makes the nose an effective incu-
bator. As the majority of diseases are air borne,
the condition of stasis is one of danger. It may
also lead to chronic catarrh o{ the mucous mem-
brane owing to the irritation produced by the
foreign material present. After having ascertained
that the nose is normal, careful and patient atten-
tion to the overcoming of bad habits may render
the person or child an unobjectionable member of
society.

ALOPECIA AND TEETH.

It is a custom now to refer to every research in
science, art or religion as a field. In many of these
fields the fence has been broken down and permits
of cattle and other animals straying, particularly
when they can prove a theory or adorn a fact. A
pure bred Holstein-Friesian bull strayed calmly
into the field of dentistry. The veterinary had noted
him to have defective front teeth and such teeth
had an intimate connection with alopecia in the
human. So the trespasser was watched, and, al-
though his brides were as pure bred as himself,
three of five calves had deficiency in teeth, with
baldness on the head and neck, though hair was
not entirely lacking. Two other calves had bald-
ness, though their teeth were norma! in appearance.
We believe there is a dentist attached to the staff
of every zoo. When the dental clinic is in every
village, attention must be turned to establishing a
zoological one !

<$> News Items. Mineola Home for Cardiac Children. — The committee in charge of this fund announces that$20,000 was collected last week on the opening day
of the drive for $100,000 to establish a home for chronic cardiac children at Mineola, L. I. An Epidemic of Hiccoughing in Budapest. — It is reported that an epidemic of hiccoughing in Buda- pest, which the physicians are unable to con- trol, is causing alarm, although as yet there have been no fatalities. It is believed by some medical authorities that this hiccoughing is a forerunner of influenza. To Abolish State Narcotic Commission. — Gov- ernor Miller, in his message to the New York State Legislature, suggested that the State Narcotic Com- mission be abolished. Health Commissioner Royal S. Copeland has expressed his approval of the pro- posal as he believes that the campaign against drug addiction can be handled by the health authorities. Dr. Copeland said that in his opinion the drug addict should be treated in a hospital, not a clinic. Suicides in Budapest. — According to dispatches from Budapest, cold and hunger are causing an average of fifteen suicides daily in that city. Aid Association, Philadelphia County Medical Society. — At the recent annual meeting of this society the following officers were elected : Presi- dent, Dr. E. E. Montgomery ; vice-president, Dr. James M. Anders; treasurer. Dr. John B. Turner; secretary. Dr. J. Leslie Davis; directors. Dr. J. Solis-Cohen, Dr. William M. Welch, and Dr. P. Brooke Bland. New Radio Call for Doctor.— "K D K E" is the new wireless call which is to be used by ships at sea to indicate that someone on board is seriously ill and that expert medical advice is needed. Medical officers are to be kept within reach of the Navy department radio to answer calls so that they will be able to diagnose and prescribe by wireless when their assistance is sought. Society of Industrial Medicine Organized. — The Wisconsin Association of Industrial Physicians and Surgeons was organized recently, its member- ship consisting of the physicians and surgeons em- ployed by industrial corporations of Wisconsin. Dr. Clare E. Schram, of Beloit, is president ; Dr. Robert A. Waite, of Milwaukee, vice-president, and Dr. Robert E. Fitzgerald, of Milwaukee, secretary- treasurer. Dr. Friedman's Turtle Serum. — The Berlin Medical Society recently held eight meetings for the purpose of discussing the value of Dr. Frederick F. Friedman's turtle serum in the treatment of tuberculosis, but failed to reach a decision that was acceptable to the membership of the society. Fur- ther experimentation was advised. This serum was investigated for more than a year by the United States Public Health Sen'ice, but was discredited in 1913. A bitter fight for and against Dr. Fried- man has raged in German medical circles since the discovery of the cure was announced. Public Health Service Activities. — The Vene- real Disease Division of the United States Public Health Service has received an appropriation of$200,000 for the next fiscal year. The amount
asked for was $336,715. The Bureau asked for$50,000 for health education and $200,000 for the control of influenza and other epidemic diseases, but the request was not granted. The sum of$80,000 is provided for the maintenance of a home
for lepers at Carville, La. An appropriation of
$50,000 was granted for the control of biological products. Association for Research in Nervous and Men- tal Diseases. — At the first annual meeting of this association, held in New York on December 28th and 29th, Dr. Walter Timme was elected president, Dr. E. W. Taylor, vice-president, and Dr. Foster Kennedy, secretary-treasurer. A commission on scientific research was appointed, composed of the officers, ex officio, and the following members : Dr. Charles L. Dana, of New York ; Dr. William G. Spiller, of Philadelphia: Dr. Hugh T. Patrick, of Chicago-; Dr. Bernard Sachs, of New York; Dr. Israel Strauss, of New York ; Dr. Lewellys F. Barker, of Baltimore, and Dr. J. Ramsay Hunt, of New York. January 15, 1921.] NEWS ITEMS. i21 Red Cross Health Work. — Chief among; the activities, during the past year, of the Health Serv- ice of the American Red Cross Society, organized about a year ago by the Atlantic Division of the society, was the establishment of seventeen health centres in New York State, six in New Jersey, and three in Connecticut, and the inauguration of vari- ous phases of health service in sixty-one other places in the division. Increase in Alcoholic Insanity in Chicago. — Cases of insanity from alcoholism have increased in the Cook County Psychopathic Hospital since pro- hibition went into effect, according to the quarterly report of Dr. James Whitney Hall. Dr. Hall re- ported an increase of thirty-three per cent, in alco- holic cases in December, 1920, over the same month last year, and of sixteen per cent, in November. A slight increase was noted in October over previous Octobers, while in September the increase was thirty per cent. Mental Disease Among War Veterans. — The Joint Committee for Aid to Disabled Veterans states that the estimated number of veterans of the world war suffering from mental and nervous disorders is 76,688. Twenty thousand of these are now in hospitals, and medical authorities say that during 1921 at least thirty thousand will need hospital treatment. The report shows that in New York State 845 veterans suffering from mental and nerv- ous disorders are being treated in thirty-nine institutions. Cornell University Endowment Fund. — Cornell University's semicentennial endowment fund amounted to$8,952,770 at the close of the campaign.
The total represents gifts from 10,114 former Cor-
nellians, or thirty-two per cent, of all Cornell alumni
and former students, and 408 other persons who
had not attended the institution. The sum of $6,- 243,917 will be used for the purpose of increasing professor's salaries, with the exception of one gift of$500,000 for the endowment of research. The
remainder comprises gifts for buildings and im-
provements, including two principal items of $1,500.- 000 for a new chemistry laboratory and$500,000
for the Medical College in New York city.

Meetings of Local Medical Societies. — The fol-
lowing medical societies will meet in New York
during the coming week:

_ Monday. January ijth. — New York Academy of Medi-
cine (Section in Ophthalmology) ; Medical Association of
the Greater City of New York (annual) ; Psychiatric So-
ciety of Ward's Island ; Yorkville Medical Society.

Tuesday, January iSth. — New York Academy of Medi-
cine (Section in Medicine); Federation of Medical Eco-
nomic Leagues (annual).

Wendesday, January igth. — New York Academy of
Medicine (Section in Genitourinary Diseases) ; Medico-
legal Society; Northwestern Medical and Surgical Society
of New York ; Woman's Medical Association of New
York; Alumni Association of City Hospital.

Thursday, January 20th. — New York Academy of Medi-
cine (stated meeting) ; New York Celtic Medical Society.

Friday, January 21st. — New York Academy of Medicine
(Section in Orthopedic Surgery) ; Clinical Society of the
New York Post-Graduate Medical School and Hospital ;
New York Microscopical Society ; Alumni Association of
Roosevelt Hospital ; Brooklyn Medical Society.

Saturday, January 22nd. — Harvard Medical Society;
Lenox Medical and Surgical Society ; New York Medical
and Surgical Society ; West End Medical Society.

Red Cross Relief for Children in Europe. — The

executive committee of the x\mcrican Red Cross
has appropriated 5,000,000 from the society's re- serve fund to furnish medical assistance for children in Europe. Dr. Livingston Farrand, chairman of the central committee of the Red Cross, in making this announcement, said that this work must not be confused with that of feeding the several millions of children in Europe who are not diseased but are threatened with starvation. The general feeding problem is being handled by the Europe Relief Council, composed of eight organizations. Personal. — Dr. Robert P. Bay has been ap- pointed a member of the Board of Supervisors of City Charities, Baltimore, to succeed Dr. J. Whit- ridge Williams, resigned. Dr. Roger S. Morris has resumed his work in the College of Medicine of the University of Cincinnati, after a year's leave of absence. Dr. Henry Cuthbert Bazett, Cheselden Welsh lec- turer of clinical physiology at the University of Oxford, has accepted the chair of physiology in the Medical Department of the University of Pennsyl- vania. Professor A. B. Macallum, of McGill University, Montreal, will leave for the Orient in March, to deliver a course of lectures, extending over a period of seven months, at the medical college in Peking, China. <^ Died. Bartlett. — In New York, on Wednesday, January 5, Dr. William Allen Bartlett, aged sixty-three years. Conrad. — In Glendale, Cal., on Saturday, December 25th, Dr. Andrew O. Conrad, aged fifty-three years. Farnham. — In Almond, N. Y., on Thursday, December 30th, Dr. L. D. Farnham, aged ninety-one years. Glass. — In Beech Bottom, W. Va., on Tuesday, Decem- ber 21st, Dr. Montgomery Walker Glass, aged sixty-seven years. HoRNE. — In Anderson, Ind., on Tuesday, December 21st, Dr. William N. Horne, aged sixty-seven years. Jack. — In Hornell, N. Y., on Friday, December 31st, Dr. Harvey P. Jack, aged fifty-five years. Jacobs. — In New York, on Thursday, December 30th. Dr. Louis Jacobs, aged thirty-nine years. KiNGSMAN. — In Washington, D. C, on Friday, December 31st, Dr. Richard Kingsman, aged sixty-six years. Knipe. — In New York, on Wednesday, January 5th, Dr. George Knipe, aged sixty-three years. Leonard. — In Broome Center, N. Y., on Sunday, Decem- ber 26th, Dr. Duncan M. Leonard, aged eighty-three years. McFadden. — In Buffalo, N. Y., on Thursday, December 23rd, Dr. James J. McFadden, aged seventy-one years. McLaughlin. — In Washington, D. C, on Monday, Jan- uary 3rd, Dr. Thomas Notley McLaughlin, aged fifty-nine years. Messenger. — In New York, on Wednesday, January 5th, Dr. Joseph E. Messenger, aged sixty-seven years. Schweitzer. — In Reading, Pa., on Sunday, December 26th, Dr. Richard S. Schweitzer, of Adamstown, aged sixty-eight years. Swift. — In Castle Creek, N. Y., on Tuesday, December 28th, Dr. Charles L. Swift, aged seventy-one years. Woodbury. — In Clifton Springs, N. Y., on Thursday, January 6th, Dr. Malcolm Sumner Woodbury, aged forty years. Book Reviews MEDICAL GYMNASTICS. Medical Gymnastics in Medicine and Surgery. By E. Bf.llis Clayton, M. B., B.C. (Cantab.), Director of the Physiotherapeutic Department, and in Charge of the Massage and Electrical School, King's College Hospital, London. New York : Longmans, Green & Co. : London : Edward Arnold, 1920. Pp. viii-159. The title is somewhat alarminfj until the nurse and doctor find it is not purposed to introduce calisthenics or acrobatic feats into daily treatment. In fact, a great many of the exercises are vicarious, for they include massage, passive movements, petrttssage, kneading, stroking, effleurage. But, some say, all this a competent massetise is supposed to know. Yes, the mechanical side, but does she know when to abstain? The one who understands the conditions underlying treatment is invaluable, the pure mechanician is a constant source of anxiety to the doctor. Those who do not know will be greatly helped by a pertisal of the book, those who do know will be surprised to find how- much they have forgotten, or how mtich they have acquired through intelligent practice. General pathology and principles of treatment stand on the threshold, then these various divisions are spoken of: skin, muscles, fractures, joint dis- eases, deformities, circulatory diseases, respiratory diseases, the genitourinary and the nervous system, concluding with a scheme of exercises and principles of reeducation. By the printer's aid, mtich wading through imi- form type is saved. The disease and its various forms are given, then their catises, symptoms and treatment, each heading in different type. A warn- ing is given to distinguish between voluntary and involuntary movements, particularly in spastic cases, because the latter do not mean recovery but exag- gerated reflexes. The popular idea that massage is simply a mixture of indiscriminate rubbing, knead- ing and stroking shrinks away with all this knowledge revealed. INDIGESTION. Textbook of Indigestion. By Dr. G. Herschell. Revised and Rewritten by Adolph Abrahams, O. B. E., M. D. (Camb.), M. R. C. P. (London), Assistant Physician to Westminster Hospital, to the Hampstead and North- western General Hospital, etc., etc. New York : Long- mans, Green & Co. ; London : Edward Arnold, 1920. Pp. 228. The laity have a wonderful atlas of their own devising in which the topography of the stomach is somewhat vague. A small boy came to a London dispensary with a mother made diagnosis. It said, "Bil 'as stumik ake," and Bil rubbed his hand over the lower part of the belly ; on which part hot cloths are usually put when ordered for the stomach. By the help of the same atlas, a person will press his hand over the stomach and say his heart is troubling him. But, nowadays, doctors are allowing patients to learn through x ray plates and flttoroscopy, and elderly nervous patients, who have taken every aperient they could get, are annoyed to find their doctor putting more emphasis on quiet mentality, good company and pleasant food than on some pill or powder. Why a fourth edition? Well, in that of 1905, organic diseases of the stomach were not specially dealt with, nor the great advance in radiology and our conception of functional disease. The reviewer has rarely met a book so clear or comprehensive. It does not minimize the slight pains of the neuras- thenic nor draw gloomy pictures of those organically diseased. He admits a certain immtmity to foods. How the rich man and the laborer might exchange dinners and both be very ill in conseqttence. That the indigestion may result not from the food, but from mental causes or environment or hurry : the contents of one meal in the stomach not being got rid of before another is ptit in. Tea and toast, muf- fins and hot cakes inctir his wrath when taken as an adjunctory meal, or early morning tea preceding breakfast only by an hour. The other day the re- viewer saw a tachyphagic fiend ptit away a bowl of soup, a meat pie and cofifee in three minutes, while his neighbor with rusks and fruit carefully munched and munched in a -style most Gladstonic. There is a time table giving the approximate time in which dififerent articles of food should leave the stomach, so the dyspeptic can see that his eggs and bacon leave the stomachic depot when his train leaves for town. The chapter on Nervous Digestion teaches what to avoid and that on Food Recipes will make obedi- ence a pleasure. Carefully read, the patent medicine man will have to close his store and seek a place which possesses no copy of Herschell and Abra- hams. Lives of rich men all remind us. They can't make their lives sublime. For the stomachs attached to them Keep them doping all the time. BACKWATERS OF LETHE. Backivaters of Lethe. By G. A. H. Barton, M. D., .Anes- thetist to the Hampstead General and Royal National Orthopedic Hospital, etc. Illustrated. London : H. K. , Lewis & Co., 1920. Pp. v-151. : This English author is cordially invited to cross j the Atlantic where he will find with his colleague, j Professor Leonard Williams, that "medicine need | not be dull as well as difficult." The fact that he j has crystallized his own wide experience for the use of beginners in his own cheerftil fashion, deal- ing with those small matters usually omitted in textbooks, will ensure him a welcome from all sttidents here. The reviewer recalls the far away times at the Society of Anesthetists, when the for- mality, in contradistinction to American ways, was only softened by cofi'ee and cake, and where, as a i newly fledged reporter, he made Dudley Buxton i produce necrosis instead of narcosis, and his con- sequent dodging of the irate speaker. What is the lure of anesthetics? asks Barton; not in the easy work, for the dental student should be well versed in the laws of heat, mechanics of valves and levers, the law of gravitation and effects \ of specific gravity in mixtures of weight or fluids, i mental and physical qualities are also necessary. He must have a well balanced mind, able to keep cool under all circumstances, good sight, hearing. January 15, 1921.] BOOK REVIEWS. 123 touch and smell. They have to tell him nmch dur- ing an operation. The lure is in the variety of the work. The prohlems are endless, arising from the state of the patient, the nature of the operation and the patient's idiosyncrasy — an unknown quantity. Though the responsibilities are great, the operation once over, the anesthetist's task is, as a rule, fin- ished. There is a certain sporting element, though the more one plays the game, the more the rules and probabilities are grasped and perfection reached. Anesthetists vary, but Barton names five years as a period for mastering the essentials, and another five to deal with every emergency. Some points on chloroform are then dealt with, also alkaloids, their use and abuse, gas, modern methods, finally, shoals and rapids. Barton com- pares American and English methods, but is cer- tainly justified in quoting his own methods based on success in thousands of cases. His rare fail- ures, frankly given, his genial way of giving infor- mation, all tempt the reader to do more than glance over this helpful volume. MOON-CALF. Moon-Calf. Bv Flovd Dell. New York : Alfred A. Knopf, 1920. ' Moon-Calf is a book so unusual in the annals of our literature that it should be read at once by everyone interested in American life and in litera- ture as a fine art. It is the biography of a young near rebel of the middle west, who develops in the extraordinarily inarticulate environment of a small lUinois town, but it is more. Floyd Dell shows here the grim and arid subsistence which the small town has to ofifer to the young man of talent — • which America herself has to offer to the young man of talent, though the author may not have meant anything so sweeping. With all this, Moon-Calf is a novel which, once started, it is impossible to put down, written in the "light and laughing" prose to which the author refers, and with a delicate and distinguished craftsmanship. 1 Of particular interest to physicians is the fact that : this book is, in a sense, a product of psychoanalysis. [ Many writers enunciate truths about the hidden I places in the human soul of whose implications they )• are only half aware — a manner of revelation. Mr. Dell is entirely articulate on that score. He does not talk about complexes, but he interprets the events of his hero's life from childhood on with a deft and sure analysis that is truly illuminating. One might almost say that this book could not have been written ' if Mr. Dell had not been aware of how Felix Fay's fear of living influenced his every action. And he shows the origin of this fear in the childhood of Felix, a dreamy, bookish, fragile child among a ^roup of hoydenish brothers and sisters and school- mates, a child who compensated for his manifest physical inferiority and his helplessness by a con- tinuous life of fantasy. Felix's great effort, like that of all such young persons, is to translate him- self into a living human being. It is not entirely Felix's fault, of course, that he grew up on dreams instead of realities. Partly his flight was due to the fact that he was so fearfully isolated. There weren't any others like him. There was no appreciable intellectual life in Maple and Vickley, nothing to feed his imagination but the incredibly bare existence of a poor middleclass family in a small middle western town. If he took to books and dreams, it was because there was nothing else to take to. The one exception of his younger days is the episode of Rose Henderson, with its brief and poignant loveliness. One cannot say that Felix was the victim of Puritanism as much as of sheer emptiness. His home was the library, where he read a jumble of everything under the sun, but it was a scattered,. ungu"ded reading. School brought him nothing in the way of intellectual stimulus. And this solitary, secluded, ingrowing life of his in books made him a personality lacking in color and positiveness. This is aptly shown in the remark of the novelist, Tom Alden, after Felix has been taken to meet him : " T ought to like him. But how can you like a person who isn't there? I like everything he says. But there doesn't seem to be anybody saying it. Darn it all, Helen, he isn't real !' " But Felix does come to himself, and this through a somewhat devious means, beginning with his intro- duction to Socialism. Socialism is for him some- thing more realistic than anything he has ever en- countered, and in the Central Branch he finds peo- ple, too, who bring him realism. There is a salutary cruelty in the verdict of Comrade Vogelsang on Felix's poetry, the pretty poems that have always met with such deferential praise. " 'You have been mooning about, writing verses about life, instead of living,' " says this healthy philosopher. "'You have been afraid to live. Most people are. Something stands between them and life. Not only economic conditions : something else — a shadow, a fear. Perhaps it is safer not to try, they think. So do you. These poems are your con- solations for not living. . . . You have a future — a great future — as a consoler of weak souls.' " Socialism plays an important part in Felix's life, partly because he is helpless economically, drifting from one factory to anotlier and hating his jobs with a feeble and futile hatred. But it is a newspaper work which sets him on his feet — newspaper work with its enforced contact with people and ideas, its joy of creation, its adventurousness. Felix is a better writer of human interest stories and dramatic critic than a news reporter, but it is in the back room of the undertaker's establishment while hunt- ing for news and talking to the rival reporter from •the other paper that he begins to learn how to meet the world he lives in. There are women in this story, of course — quite a number of them, beginning with the half dreamlike playtime with Rose Henderson when Felix is a child and ending with the inherently conventional Joyce Tennant. There is also Margaret, who was to him unreasoning romance, and there is Daisy, whose offering, though sincere, is somewhat too sordid. But Felix does not marry in this book, though it is not exactly his fault. At the end Joyce turns him down for a protective male, which P'elix decidedly is not, and Felix is left with his face set toward Chicago — the next step. It is a dififerent Felix, though, from the early 124 BOOK REVJEIVS. [New York Medical Journal. helpless youth — a Felix who has learned the joy of artistic creation and of love, who has found his work — for the time being — and who has learned that a hostile world cannot batter down his indi- viduality. He has learned, moreover, that there are others like himself. This is perhaps the most im- portant lesson of all. He has become a personality. All this is, of course, much more a personal record than a criticism of American culture, though it is that as well. But it is primarily that absorbing story which every writer longs to put on j)aper and usually does — the story of finding himself. It is because FeHx reaches out in many directions that Moon-Calf has so large a scope. The book should be widely read. With its selfknowledge, -t.- sure yet delicate incisions into the fabric of our social and economic life, its fluid and lovely lechnic. it is a significant first novel and certainly a most .lote- worthy book. YESTERDAY AND TODAY. Caius Graccluis. A Tragedy. By Odix Gregory. With an Introduction by Theodore Dreiser. New York : Boni & Liveright, 1920. Pp. 172. Dreiser's introduction has performed the re- viewer's task so well that little remains to be said. That little, however, afifords opportunity to empha- size the values that this virile work brings so unex- pectedly to our present day reading world. It is an unexpected thing to come. upon this drama of measured beauty, strength, and quiet but absolutely fearless setting forth of truth. Dreiser has boldly placed the writer high in the realm of letters both for his thought and form. One wonders at first if the place has been meas- ured too high. Here is a drama of an almost for- gotten history. Any message for today may be lost in the dullness with which time tarnishes the most brilliant of events. Then as one reads and finds that these old pages have been so clearly evoked that each character does live and breathe, another objection arises. There is startling simi- larity to the evils of today which go about in the same sheep's clothing. There is sharp conflict be- tween protection at any price, utilized for any selfish end, and, opposed to it, the sincerity of real con- structive expansion with opportunity for each and all. It seems as if the dramatist must simply have wrenched present economic conditions out of their setting and readapted a historical garb to them. Gregory himself has anticipated such a charge by giving us in footnotes as well as in his preface the simple facts and the unadorned statement of them by the historians of that far distant Rome. The reader can only feel, therefore, with Dreiser, that Gregory has something to say, something that is eternally human, that recalls men today as it would have done in that past age, to judge clearly between two aims, incompatible, irreconcilable. One is genuinely constructive, self forgetful in engaging the self in something larger than the narrow ends of its own gratification. On the other hand, is the self steeped in greed of power, wealth, pleasure, and stupidly or maliciously fearful of progress which threatens such arrogated possessions? So well does the drama represent these contrasted aims, each in its own way, that the hero is broadly human in his heroism, awakening responsive chords of our best aspirations, evoking righteous indignation in his defeat; and the drama must be read closely to detect the machinations devoted to his defeat. For here is the same plausibleness with which selfishness today deceives the very elect, those who would fain follow what is worthy. Surrounding these in the play are to be seen also those of the herd who hearken to the last voice which has spoken, the unthinking men who are swayed indifferently to one side or the other. It is true that the character drawing is distinctly individual. The long speeches, as Dreiser has said, we do not avoid. One returns rather fascinated to reread the truth they express, to discern the charac- ter lineaments they contain. Lydia's long harangue in Act IV gives a vivid picture both of the woman and the man who prostitute one another and society to their own gain or pleasure. The setting of the speech saves it from being a merely moralistic dis- play of the dramatist and makes it only more poignantly relevant to the drama's purpose. It can be agreed that the drama is indeed vital enough to be brought to the stage. CLEMENCEAU'S SHORT STORIES Tl'.c Surprises of Life. By Georges Clemenceau. Trans- lated by Grace Hall. Garden Citj' and New York: Doubleday. Page & Co., 1920. Pp. vi-326. The name of this book is the only thing that invites adverse criticism. It is inadequate ; it be- longs to the conventionality which the author so gracefully flays throughout these stories. Perhaps in its original form the name conveys more of the exquisitely subtle flavor of the book. The writer discloses facts in character and behavior which only a keen observation would discover. The existence of these realities in his sometime neighbors, even feathered ones, might come as a jolting surprise to many readers were they less cleverly brought to view. But so skillfully does Clemenceau turn these natures over to discover their reverse sides that his revelations strike gently. So keen is his probing, so accurate his anal}-sis of what lies there, that his revelations cannot be taken lightly. They arouse serious reflection upon human nature. The reader is awakened "to share tlie writer's rare sympathy, his patient understanding of the slow- ness, the unevenness of human development. He comes not to censure the fumbling stupidity of lives bound under custom, unaware of their own possi- bilities. There is a genuine pity, rather, not un- tempered with the brightness of hinnor. With this the reader follows the peasant, the monotonous toiler, the cunning selfseeker even, and those also who, bound in by conventional demands, find private tragic exercise for the irrepressible flames of hatred, the distortion of what might have been love. It is a pity which is rather a sympathetic attempt better to understand human society and the limitations and conflicts which continue in it. as the soil out of which, slowly, something else may arise. The shafts of censure direct themselves in a satire no less true because gracefully tipped. These arc aimed against cupidity, the brilliant traditions which blazon upon such foundation, the approval of men and women for only these protecting appears January 15, 1921.] BOOK REVIEWS. 125 ances. Otherwise the wisdom of this keen analyst is proffered in the brighter and sadder notes of the countryside, the picture that wins the heart to inner reaHties. These find their own, sometimes, in spiti of the outward smothering conceits. They flourish even when in the end they must pay penalty to the latter. No one can read the book thoughtfully without a closer realization of these inner truths of human lives, and without a thrust of responsibility toward that which is within and away from the falseness without. In this insistence on the individual and his sincerity to himself one catches a glimpse of the source of Clemenceau's own unique power, that of the strong man of France. I AN ADVENTUROUS DOCTOR. ' The Story of Doctor Dolittlc. Being the History of His Peculiar Life at Home and Astonishing Adventures in Foreign Parts. Never Before Printed. Told by Hugh Lofting. Illustrated by the Author. New York : Fred- erick A. Stokes Company, 1920. Pp. 180. I Put yourself in his place, leave aside the incredu- lity, the superciliousness of unmellowed age. Curl up in an armchair with Doctor Dolittle's book, recall the pleased expectancy with which you once received a new book, and, in a short while, you will find your big toe waggling and a red flush of gratified desire aflame on your cheek, and a smile of full content, like Prince Bumpo on page 96. John Dolittle, M. D., loved animals, and eventu- ally, growing poorer, became a doctor for animals, and his clever parrot taught him animal language, but he did not make much money. Suddenly, he had a wire from Africa, saying a dreadful sickness had attacked the monkeys. Would he come and help them? Well, he had no money, but a sailor lent him a boat, and then the fun begins. He fairly tumbles into adventures, wild beasts, pirates, a mix- ture of all that children love, with a wild disregard of probabilities or commonplace sequences. The author evidently knows children well. He does not talk down to them or slyly insert sentiment to please the grownups, so that they may say, "What a sweet story! I must get it for Tommy." No. he does not care for grownups one bit ; just loves the children. ^ New Publications Received. [We publish full lists of books received, but we acknowl- edge no obligation to review them all. Nevertheless, so far as space permits, we review those in which we think our readers are likely to be interested.] MASTER EUSTACE. By Henry James. New York : Thomas Seltzer, 1920. Pp. 280. COLLECTED POEMS. By ALFRED NoYES. Voume HL New York: Frederick A. Stokes Company, 1920. Pp. ix-315. aviation medicine in the .a. e. f. Prepared in the Office of the Director of Air Service. Washington : Government Printing Office, 1920. Pp. 322. the rockefeller foundation international health BOARD. Sixth Annual Report. January 1, 1919-December 31, 1919. New York : 61 Broadway, 1920. Pp. xiii-210. the seven wives of BLUEBEARD AND OTHER MARVELOUS TALES. By Anat(5le France. a Translation by D. B. Stewart. London and New York : John Lane Company, 1920. Pp. vi-216. POOR WHITE. By Sherwood Anderson. New York: B. W. Huebsch, Inc., 1920. Pp. 371. MARIE Claire's workshop. By Marguerite Audoux. Translated by F. S. Flint. New York : Thomas Seltzer, 1920. Pp. 239. the golden barque and the weaver's grave. By Seumas O'Kelly. New York and London: G. Putnam's Sons, 1920. Pp. 253. the revels of orsera. .a. Mediaeval Romance. By Ron- ald Ross. New York: E. P. Dutton & Co., 1920. Pp. vi-393. instinct and the -unconscious, a Contribution to a Biological Theory of the Psychoneuroses. By W. H. R. Rivers, M.D., D.Sc, LL.D., F.R.S., Fellow and Praelector in Natural Sciences, St. John's College, Cambridge. Cam- bridge: The University Press, 1920. Pp. viii-252. the essentials of histology. Descriptive and Practical For the Use of Students. By Sir Edward Siiarpey Schafer, F. R. S., Professor of Physiology in the Uni- versity of Edinburgh ; Formerly Jodrell Professor of Physi- ology in University College, London. Eleventh Edition. Philadelphia and New York: Lea & Febiger, 1920. Pp. xi-577. syphilis. By Loyd Thompson, Ph. B., M. D., Physician to the Syphilis Clinic, Government Free Bath House ; Visit- ing Urologist to St. Joseph's Hospital ; Consulting Patholo- gist to the Leo N. Levy Memorial Hospital, Hot Springs, Arkansas, etc. Illustrated with Eighty-one Engravings and Seven Plates. Second Edition, Thoroughly Revised. Philadelphia and New York : Lea & Febiger, 1920. Pp. xix-486. CLINICAL OPHTHALMOLOGY FOR THE GENERAL PRACTITIONER. By A. Maitland Ramsay, M.D., Fellow of Royal Faculty of Physicians and Surgeons, Glasgow ; Lecturer on Oph- thalmology, University of Glasgow ; Ophthalmic Surgeon, Glasgow Royal Infirmary, etc. With Foreword by Sir James Mackenzie, M.D., F.R.S. London : Henry Frowde (Oxford University Press) and Hodder and Stoughton. 1920. Pp. xx-500. A TEXTBOOK OF PHARMACOLOGY AND MEDICAL TREATMENT FOR NURSES. By J. M. Fortescue-Brickdale, M.A., M.D. (Oxon.) M.R.C.P. (Lond.) Capt. R.A.M.C. (T.F;.) ; Physician to the British Royal Infirmary and Clinical Lecturer in the University of Bristol ; formerly Lecturer on Pharmacology in the University of Oxford. London : Henry Frowde (Oxford University Press) and Hodder and Stoughton, 1920. Pp. xiii-392. principles of biochemistry. For Students of Medicine, Agriculture and Related Sciences. By T. Brailsford Rob- ertson, Ph. D., D. Sc., Professor of Physiology and Bio- chemistry in the University of Adelaide, South Australia; Formerly Professor of Biochemistry in the University of Toronto ; Professor of Biochemistry and Pharmacology in the University of California. Illustrated with Forty-nine Engravings. Philadelphia and New York: Lea & Febiger, 1920. Pp. xii-633. tropical OPHTHALMOLOGY. By RoBERT HeNRY ElLIOT, M.D., B.S. (Lond.), Sc.D. (Edin.), F.R.C.S. (Eng.), Lieutenant-Colonel I.M.S. (Retired), Late Superintendent of the Government Ophthalmic Hospital, Madras and Professor of Ophthalmology, Medical College, Madras, Honorary Fellow and Gold Medallist of the American Academy of Ophthalmology and Otolaryngology, etc. With 7 Plates and 117 Illustrations. London: Henry Frowde (Oxford University Press) and Hodder and Stoughton, 1920. Pp. xxiii-525. HISTORY AND BIBLIOGRAPHY OF ANATOMIC ILLUSTRATION IN ITS RELATION TO ANATOMIC SCIENCE AND THE GRAPHIC ARTS. By LuDWiG Choulant. Translated and Edited with Notes and a Biography by Mortimer Frank, B. S., M.D., Secre- tary, The Society of Medical History, Chicago; Attending Ophthalmologist, Michael Reese Hospital, Chicago. With a Biographical Sketch of the Translator and Two Additional Sections by Fielding H. Garrison, M.D., and Edward C. Streeter, M. D. Chicago : The University of Chicago Press, 1920. Pp. xxvii-435. Practical Therapeutics and Preventive Medicine A Compendium of Treatment and Prophylaxis, Original and Adapted Treatment of Neurosyphilis by the Intraspinal Route. — Albert Keidel and Joseph Warle Moore (Bulletin of the Johns Hopkins Hospital, Novem- ber, 1920) gave twenty-five cases of neurosyphilis intraspinal injections of mercurialized serum, fol- lowed within twenty-four hours by an intravenous injection of arsphenamine. This method of treat- ment was designed to test a conclusion of Swift that local irritation may increase the permeability of the meninges. Mercurialized serum was chosen be- cause of its irritating ef¥ect, and intraspinal treat- ments were given in courses, usually of six treat- ments, administered one each week, and each course was followed by ten to twelve weeks of mercury inunction. The clinical resiilts of this treatment were good in about sixty per cent, of the cases, but the serological results were poor in practically all the groups treated. A comparison of the data with those of other workers shows that the results ob- tained from mercurialized serum, used by the method the authors describe, are inferior to results obtained either by themselves or by others with the Swift-Ellis method. The conclusions drawn are that intraspinal therapy is a necessary and rational adjunct in the treatment of neurosyphilis in cases which fail to respond to routine antisyphilitic treat- ment. The mode of action of intraspinal medica- tion does not depend upon increased permeability of the meninges. Aseptic meningitis produced by intraspinal injection of irritants may prove an un- toward rather than a beneficial factor in the treat- ment of neurosyphilis. Different Types of Streptococci in War Wounds. — Pierre Pruvost (Paris medical, Feb- ruary 21, 1920) points out that in the bacterial flora of war wounds two sorts of streptococci may be dififerentiated. The first is pathogenic and causes a severe, febrile constitutional reaction ; the other causes no marked general symptoms. The first type consists nearly always of hemolytic strepto- cocci, and forms homogeneous chains composed of regularly arranged cocci or cocci undergoing repro- duction by fission. The second type usually con- sists of nonhemolytic streptococci, and the chains formed are not homogeneous, being composed of unlike, unequal, and irregular cocci. The cultures of the second type are generally more robust than those of the first. Where a distinction between the two types within twenty-four or forty-eight hours is imperative, precluding isolation and secondary identification, one should endeavor to establish the distinction on the basis of the foregoing morpho- logical characteristics. In doing so the length of the chains of bacteria, the rounded or oval outlines of the cocci, as well as their size, should be dis- regarded, attention being directed exclusively to the regularity or irregularity of the several cocci com- posing the individual chains. Great length and curling of the chains are not characteristic of the streptococci. Even at the first inoculation in bouil- lon enterococci similarly disposed were noted. A Pharmacological Study of Benzyl Benzoate. • — Edward C. Mason and Carl E. Pieck (Journal of Laboratory and Clinical Medicine, November, 1920) say that, owing to the fact that a considerable number of clinical conditions, such as are due to increased activity or increased tonus of the in- testinal tract, excessive or abnormal contraction of the uterus, bronchial spasm, etc., have been described as being benefited by the use of the benzyl esters. They have attempted to study the mechanism by which these conditions are relieved, and to ascer- tain the concentration of the drug in the blood necessary to produce the desired results. Their experiments with dogs are fully reported, and the results given in detail. Genital Tuberculosis in the Male. — J. Dellinger Barney (American Journal of Surgery, August, 1920) presents among his conclusions the following which he considers of importance: 1. The epididy- mis is the primary focus in the genital tract. 2. It is always secondary to a focus elsewhere in the body, this focus being situated most often in the lung. 3. The prostate and seminal vesicles are invaded by the disease early and often, but after re- moval of the epididymis clinical cure is finally estab- lished. 4. The second epididymis becomes involved in at least half the cases, but involvement of this organ may be obviated by early resection of its vas deferens. 5. Orchidectomy is unnecessary if the testicle is free from disease, and even if affected the diseased portion can be successfully removed in many instances. Even a portion of one or both testicles is worth saving, both on account of the internal secretion and the mental effect upon the patient. After castration the sexual function may be unimpaired. Value of the Wassermann Reaction in Obstet- rics. — J. Whitridge Williams (Bulletin of the Johns Hopkins Hospital, October, 1920) found that 449 women, delivered between April, 1916, and December 31, 1919, gave a positive Wassermann test, the incidence being much greater in the black than the white woman, 16.29 and 2.48 per cent, respectively. The figures showed that less than one half of such women will have syphilitic chil- dren. The cases were divided into three groups, those that had been well treated, those which were imperfectly treated, and those which were not treated at all, the incidence of syphilitic children being for these groups 6.7, 33.2, and 48.5 per cent., respectively. However, of sixty-five women giving a negative Wassermann test, forty-three of their children were definitely syphilitic, eleven others died but were not autopsied, three were negative at autopsy, and eight were discharged in good con- dition. The information obtained from the Was- sermann tests made on the fetal blood is not con- sidered to be commensurate with the time consumed nor the money spent on such investigations. It is also considered hazardous to draw any conclusions January 15, 1921.] PRACTICAL THERAPEUTICS A.XD I'REl-EXTIVE MEDICINE. 127 concerning the condition of the placenta or of the child from the existence of a positive maternal Wassermann during pregnancy. The microscopical examination of the placenta tallied with the cHnical and anatomical findings in the child in from eighty to ninety per cent, of the cases, which is a marked contrast to the forty per cent, obtained from a positive maternal Wassermann. Williams discusses Colles's law, and states that in his opinion the pos- sibility of spermatic infection and the admissibility of Colles's law have not yet been conclusively proved or disproved. Virulent Diphtheria Bacilli Carried by Cats. — James S. Simmons {American Journal of the Medi- cal Sciences, October, 1920) reports a case in which an elderly woman developed a fatal diphtheritic pharyngitis after close contact with a cat which had been sick one week. A second cat which had been in contact with the first cat became sick and died ten days later. The patient had a grayish brown pseudomembrane covering her uvula, tonsils, and posterior pharynx. The first cat had a small yel- lowish gray pseudomembranous ulceration in the left nasal passage, the second cat showed ulcera- tions of both vocal cords covered with a grayish- white false membrane. Diphtheria bacilli of inter- mediate virulence for guineapigs were isolated from all three lesions. Treatment of Diphtheria Carriers. — A. R. Era- ser and A. G. B. Duncan {Lancet, November 13, 1920) differentiate between a "positive throat" and a "true diphtheria carrier." The latter carries bac- teria which retain their virulence despite the most energetic disinfection. Stock diphtheria vaccine cures the positive throat, but up to the present time no thorough cure has been offered for the true carrier. The authors base their work on the theory that in a carrier there is equilibrium between the power of immunity of the individual and the toxin. A detoxicated Klebs-Loffler vaccine, prepared after the manner of E). Thompson, was used in three cases outlined in the paper. All lethal bacteria dis- appeared after inoculations of constantly increasing concentrations. It is pointed out that the treatment may be used on convalescents in case of delayed resolution, and the method apparently offers im- munity to those exposed to infection. Diphtheria Bacillus Carriers. — C. G. Guthrie, J. Gelien, and W. L. Moss {Bulletin of the Johns Hopkins Hospital, November, 1920) report the re- sults of an extensive investigation, covering the examination of eight hundred school children. From this study they conclude that the diphtheria bacilli present in a majority of healthy carriers are avirulent, that such bacilli cannot produce diph- theria, and that there is no proof that they can acquire virulence. It is, therefore, evident that carriers of avirulent diphtheria bacilli are not a menace to anyone in particular or the community as a whole, and interference with their liberty on the grounds of their being carriers is not warranted and is unjustifiable. The standard guineapig test is beheved to be a safe one for virulence, but there is an urgent need for a simpler, quicker, and less expensive virulence test to be developed. The carrier of the virulent diphtheria bacillus is of course another matter, and while it is believed that the danger from such carriers has perhaps been over- estimated, the authors recognize the fact that diph- theria bacilli derived from such a source may give rise to the disease in susceptible persons. The Effect of Diphtheria Antitoxin in Pre- venting Lodgment and Growth of the Diphtheria Bacillus in the Nasal Passages of Animals. — J. Gelien, W. L. Moss, and C. G. Guthrie {Bulletin of the Johns Hopkins Hospital, November, 1920). The object of this investigation was to determine whether antitoxin adrriinistered subcutaneously would prevent the subsequent lodgment and growth of diphtheria bacilli in the nasopharynx. Guinea- pigs, rabbits and cats were used. The production of nasal infection or infestation with Bacillus diph- therise was quite inconstant, even when the organisms were introduced directly into the nose, and the dura- tion of infection was usually quite brief. The health of the animals was apparently not affected by the mere presence of the bacilli in the nose. The occur- rence and duration of infection were independent of the virulence of the strain of organism inocu- lated, and were wholly unaffected by the previous administration of antitoxin. Treatment of Single Ostosis of Long Bones. — Reel and Hugger {Military Surgeons. September, 1920) state that the individual case determines the treatment. Should the exostosis be superficial and subject to repeated irritation or injury the possi- bility of sarcomatous change resulting therefrom must be recognized, and the outgrowth removed. Removal is also indicated when the tumor mass is found in such a position as to produce a mechanical derangement in the normal function of a joint, muscle or tendon. The same applies when the exostosis is encountered along the course of impor- tant nerves or blood vessels and producing nervous or circulatory complications. When the bony tumor is innocentlv situated, it can be left unmolested. Treatment of Goitre with Radium. — -A. N. Clagett {Illinois Medical Journal, October, 1920) believes that radium should be given a trial in exophthalmic goitre, because there is no mortality, no scar, no pain, and only three or four days' hospitalization. Its advantages over the x ray are that it produces no discoloration of the neck, there is less time consumed in the treatment, and it is simpler to apply. The selective action of radium destroys the harmful cells, while not disturbing the healthy cells. Surgery has not been necessary in any one of forty-seven cases extending hack over three years. Etiology and Treatment of Gastric Ulcer. — fohn F. Van Paing ( Auicrica)i Medicine. Novem- ber, 1920) firmly believes that infection is the sole cause of gastric ulcer ; that gastric drainage is a myth, and that gastroenterostomy is to be done only to relieve obstruction to the passage of food or to diminish the irritation of a pyloric ulcer. Ulcer in the corpus is to be treated by excision with the cautery and closure without gastroenterostomy. Small stomata prevent the vomiting, pain and diar- rhea so common in large openings made for "gastric drainage and rest." 128 PRACTICAL THERAPEUTICS AND PREVENTIVE MEDICINE. [New York Medical Journal. Value and Significance of Blood Pressure in Obstetrics. — Albert G. Schuize {Minnesota Medi- cine, December, 1920) considers that a series of blood pressure readings properly taken, rather than a series of urine analyses, serve as an index of the eclamptic or noneclamptic condition of the patient. The normal range of blood pressure during preg- nancy is between 100 and 130 systolic; if it be below 100 be prepared for shock, if over 150 it is no longer normal. , Treatment of Eclampsia. — James A. Martin (Charlotte Medical Journal, August, 1920) guards against eclampsia by examining the urine every two weeks. Do not lay too much stress on negative findings. The blood pressure should be taken regularly as it is of great importance. He does not consider the use of veratrum viride advisable. In every case of actual eclampsia the uterus' should I)e emptied as quickly as possible, preferably by Cesarean section. Surgical Treatment of Cerebral Hemorrhage in the Newborn. — A. C. Strachauer (Minnesota Medicine, December, 1920) writes that untreated cerebral hemorrhage is responsible for fifty per cent, of stillbirths and deaths of infants within the first week of life. The coagulation and bleeding time estimation should become a routine procedure in the newborn, followed by the injection and transfusion of blood when indicated. Infratentorial hemor- rhage of infancy may be treated by lumbar punc- ture ; supratentorial hemorrhage requires prompt l^erformance of a craniotomy. The Treatment of Syphilis of the Central Nervous System. — Clyde L. Cummer (Ohio State Medical Journal, September, 1920) summarizes the treatment as follows : It must be intensive and pro- tracted; in some manifestations it may be utterly powerless. Syphilitics should be treated vigor- ously and should be kept under observation until clinical and laboratory examinations prove that the infection has been eradicated in the nervous system as well as elsewhere. Rest and Exercise in the Treatment of Heart Disease. — Joseph H. Pratt (Southern Medical Journal, July, 1920) says that rest was formerly thought to weaken the heart, but is now known to act beneficially by increasing the reserve force of the enfeebled heart. The reserve force measured by the vital capacity can be greatly increased by rest alone. Proof is lacking that exercise strengthens the degenerated heart. Absolute rest is of great value in the treatment of angina pectoris. Pneumonia in a Woman with a Habitual High Blood Pressure. — J. Konikow (Boston Medical and Surgical Journal, July 1, 1920) reports a case of this nature in a woman of fifty-four whose blood pressure for the preceding two years had been between 225 and 275, despite repeated attempts to reduce it. Pneumonia reduced it to 130 within three days. Its rise was welcomed as the surest sign of approaching recovery and when it had reached its habitual height the patient had recovered. The moral drawn is to leave high blood pressure alone, if its cause cannot be removed. In itself it is Nature's means of selfdefense. Sugar in the Blood.— R. L. M. Wallis and C. D. Gallagher (Lancet, October 16, 1920) have devised a convenient and accurate means of estimating sugar in blood. Only a few drops of blood are required. The blood is absorbed on a weighed blotting paper, the sugar extracted, and estimated by comparatively simple operations. There is no inconvenience to the patient, and the analysis is of great utility in diagnosis and treatment. Effects of Feeding with Calcium Salts on the Calcium Content of the Blood.— W. Denis and A. S. Minot (Journal of Biological Chemistry, March, 1920) foimd that it was impossible to in- crease the calcium content of the blood of six normal human subjects by the daily ingestion of calcium lactate for a period of six to ten days. Experiments were then carried out on rabbits and cats, and it was sometimes possible to increase the calcium content of their blood by feeding with cal- cium salts, if the original calcium content of the blood was rather low. Pregnancy in a Rudimentary Horn of the Uterus. — O. Paul Hempstone (Surgery, Gyne- cology and Obstetrics, November, 1920) states that with more careful history and examination, the diagnosis of this condition can usually be made. In all cases of rudimentary cornua of the uterus the pedicle should be examined by serial sections to confirm the presence of a microscopical canal through which impregnation occurs. All rudimen- tary cornua should be removed so soon as the diag- nosis is made. Function of Corpus Luteum. — Edward H. Ochsner (Surgery, Gynecology and Obstetrics, November, 1920), in a series of observation on the use of corpus luteum, concludes as follows: 1. That an unabsorbed false corpus luteum prevents ovulation and is a common cause of sterility and that the expression or excision of such a false corpus luteum invariably brings on menstruation. 2. That the excision or rupture of a true corpus luteum invariably results in interruption of pregnancy, at least during the early months of preganacy, and that it may be looked upon as a common cause of abortion. 3. That an injury to either the true or false corpus luteum may simulate ruptured extra- uterine pregnancy. Effects of the Various Toxemias upon the Eye. — W. H. Wilmer (Archives of Ophtlialmology, September, 1920) says that whatever may be the eti- ology of the ocular expression of the toxemia, the first thing to be done is to eradicate all toxic sources, and then to simulate nature's measures by bringing increased numbers of leucocytes to the zone of ac- tivity. This may be accomplished by the local use of hot applications, and, as certain stages of the in- flammation, dionin and subconjunctival injections. Nearly all involvements of the anterior portion of the uveal tract require tropine. Deficiency in the secretion of glands should be supplied by organ therapy. In case of retinal hemorrhages accom- panied by a prolonged coagulation time, the use of lime salts is indicated. In all toxemias the gastro- intestinal tract must receive attention both in regard to diet and therapeutics. Miscellany from Home and Foreign Journals Developmental Forms of the Spirillum of Re- lapsing Fever. — Ardin-Delteil and Derrieu (5m/- letin dc I'Academie de medecine, March 23, 1920) found various hitherto undescribed forms of the spiriHum of relapsing- fever in the cerebrospinal fluid, blood and pleural and joint effusions in cases of this disease. In the blood stream there were found, apart from the well known spirilla, small granular bodies and short or elongated rods, all highly motile, and persisting in the blood in the interval of apyrexia and even for a time after the final defervescence. These bodies were also seen, though inconstantly, in the cerebrospinal fluid and pleural and joint fluids. There were also found in the same fluids structures analogous to the Balfour or Leishniann bodies. When fixed and stained, these structures appeared as rounded, oval, or ir- regularly shaped bodies, ^shaped somewhat like red corpuscles, and measuring two to five microns in diameter. At the periphery of each were seen a large number of minute granules and, when derived from the cerebrospinal fluid, also long, fusiform bodies nine or ten microns in length, sometimes curved, and with an elongated nucleus. Further, the source of all these bodies was found in the cerebrospinal fluid of two patients in the form of large bipartite cells thirty to forty microns in diameter and presenting the appearance of proto- zoa. Each of these cells contained two nuclei, and at its surface showed numerous pedunculated pro- cesses, some eventually breaking oi¥ and giving rise to the granular and fusiform bodies already men- tioned. In the younger protozoan forms the pro- cesses were represented merely by slight surface elevations. Apparently the usual method of repro- duction of the protozoon is by ordinary kinesis. Under certain circumstances, however, possibly when the parasite is in a weakened condition, the cell goes through a process of parthenogenesis whereby granular and fusiform bodies are set free from its periphery. Godlewski's experiments have shown that even such small, fragile, unnucleated fragments may later reproduce the active virus. Social Service and the Clinic. — Alfred C. Reed {Boston Medical and Stirgical Journal, May 6, 1920) refers the criticisms of the free public clinic to one of three heads: 1. Abuse of the clinic by patients able to pay. To whatever degree this is true, the criticism is justified. He is of the opinion that the bulk of those who appear to be able to pay should be classed among the borderline cases, which require judgment and social study, and that the prevention of this abuse rests with the social service department. 2. Clinics act as feeders for the pri- vate practice of the attending staff. In so far as patients are found by the social service department to be able to pay, it is right that they should be referred to members of. the staff in rotation as private patients. 3. Poor service to the patient, wholesale medical practice, aiming at number and quantity, rather than careful, efficient, scientific work. Full and careful clinical records, preserved in a permanent file, will go far toward improving the character of clinic service. Not a large clinic, but one characterized by careful and accurate diagnosis and treatment, should be the objective. The functions of the clinic are first, service to the patient ; then in order, service to the doctor, to the student, and to the community. The functions of the social service department are given as three ; — 1. Followup for, a, social relief of patients; b, continued treatment; c, protection and care of con- tacts and families. 2. Investigation of patients applying for admission to clinic. 3. Training of nurses and social workers. The relation of the social service department to the clinic has not yet reached its full and proper development. This development requires cooperation and greatly in- creased mutual knowledge on the part of the social workers and the medical staff of the clinic. The work of the clinic, comprising all that is included in social and scientific medicine, can best be trans- lated to the community through the agency of the social service department. Epidemiology and Etiology of Influenza. — Al- lan J. McLaughlin (Boston Medical and Surgical Journal, July 1, 1920) says that it is probable that influenza is a disease of great antiquity, and that the cause of the world wide pandemic and interpan- demic outbreaks is the same. With a strong pre- dilection for the winter months we have influenza with us every year — and in retrospect we can detect in the mortality statistics outbreaks reaching epi- demic proportions in twenty-two out of the thirty years since 1889. In 1918-19 the attack rate varied from fifteen to forty per cent., and seemed to be highest in the age group five to nine — declining in each successive age group except twenty-five to thirty-four, which exceeded the rate for the group fifteen to twenty-four. The incidence in 1918-19 was greater in females than in males, and the disparity was most noticeable in the ages from twenty-five to forty, indicating, according to Frost, that the females from fifteen to foi-ty-five were either more susceptible or more intimately exposed to infection than males of the corresponding age. Case fatality in the 1918-19 epidemic was about two per cent, and was slightly higher in females under fifteen, and very much higher in females over sixty than in males of corresponding ages. From fifteen to sixty the case fatality was much higher in males. There was great variation in forty large cities in explosiveness of the epidemic and in the severity as measured by the excess death rates for the entire epidemic period. There seemed to be some correlation between explosiveness and the severity as measured by excess death rates — the greatest mortality being usually, but not always, in cities with a high explosive index. There was little consistency in the explosiveness of the two epi- demics, 1918-19 and 1920, upon comparing the indices in the various cities. Cities with a high explosive index in 1918-19 often had a low index in 1920. Most cities with a high explosive index for 1920 had a low index for 1918-19. Memphis, Nashville, and Washington had a high index of loO MISCELL.IXV FROM HOME AXD FOREIGN JOURKALS. I New N'ork Mf.dual Journal. explosiveness in both epidemics. There seemed to be some correlation between explosiveness and the general death rate and the rates for the four prin- cipal caus.es oi death — pneumonia, tuberculosis, heart disease, and nephritis. There seemed to be considerable correlation between the total excess death rates for the epidemic periods and the general death rate and the death rates for pneumonia, tuberculosis, heart disease, and nephritis. All the evidence points to an immunity of relatively short duration, probably of months rather than years. The etiological cause is unknown. There is not sufficient evidence to warrant the view that the bacillus influenzae is anything more than a second- ary invader. The claims for a filterable virus are strong, but much additional work will be necessary to make certain many things which are now only possibilities. A survey of the whole field and of all available literature has convinced the writer that while further epidemiological studies will have great value and be of intense interest, they will not furnish a solution of the problem. We must have more intensive, comprehensive and sustained laboratory research, using the body fluids and secretions of influenza patients for material, if we hope to solve the problem and secure the biological aids which we now lack for the prophylaxis and treatment of influenza. Unusual Cases of Mastoiditis. — liarold Hays {American Joiinial of Surgery, September, 1920) says that cases of mastoiditis in New York last winter not only reached alarming number.s but presented unusual complications of a severe nature. In former years it was believed that in ninety per cent, of the cases of acute catarrhal and acute sup- purative otitis media, where it was necessary to incise the drum, recovery took place within a few days or a week, and that in only a small percentage of these cases did mastoiditis actually develop. Last winter, however, these figures were reversed ; mas- toiditis developed in the majoi-ity of the cases of acute otitis media. In most of these cases acute suppuration of the middle ear developed, without any previous> warning. Some of them occurred after influenza, but the majority of them occurred where there was nothing to make one think that there was going to be any real trouble. In the majority of these cases, the drums were incised as soon as any bulging occurred, and it was the author's invariable practice to have a culture made from the discharge from the incision as soon as possible. These cultures showed a variety of or- ganisms. In the majority of cases, particularly those in which there were complications, the or- ganism was the streptococcus hemolyticus. The blood counts in these cases ranged from 14,000 to 25,000 white blood cells, with a polynuclear count from seventy-five to ninety per cent. The fever was usually high, but in some of the cases where, although the temperature might have been high at the onset of the trouble, after the drums were in- cised, it generally went down to normal, and remained there regardless of whether the mastoid was involved or not. In two cases the temperature had risen to 106°, and after the drums were incised, gradually went down to normal and stayed normal. However, the symptoms of mastoiditis progressed until it was imperative to operate, and in both in- stances a total destruction of the mastoid cells was found. The author reported several interesting cases and presented the following conclusions: 1. The number of cases of mastoiditis has become alarm- ingly large since January, 1920. 2. The majority of infections have been due to the streptococcus hemol>'ticus. Although this organism is morpho- logically the same as ever, there is evidence that its virulence is greater and that it has a peculiar ability to destroy bone beyond the mastoid region. 3. The zygoma, beyond the cells usually found, has been found diseased in many cases, causing a severe radiating neuralgia of a supraorbital character. 4. Symptoms simulating a localized meningitis, in- definite in nature and sometimes suspicious of men- ingitis lethargica (sleeping sickness), have been seen in many cases. 5. Examination of the eyegrounds is most important in suspected cases of sinus throm- bosis. A choked disc often is found on the side on which the sinus is involved. 6. Laboratory exam- inations are of the utmost importance. 7. Trans- fusion (by the simple Unger method) was a life- saving measure in two of the cases cited. Lethargic and Myoclonic Forms of Epidemic Encephalitis. — Pietro Boveri (Journal of Nervous and Mental Diseases, May, 1920) reports cases of epidemic encephalitis presenting the unusual symp- toms of myoclonic convulsions, both rhythmic and partial, as though produced by an electric current. Dubini in 1846 described a form of disease termed by him electric chorea, a term which in years since has been applied to many manifestations which should probably be better classed as typhoid or malarial fevers or Jacksonian epilepsies. The dif- ferent symptomatology between the lethargic and the myoclonic types of encephalitis suggests a dif- ferent pathological localization of the virus. In the lethargic form the localization is particularly on a level with the central peduncles and the locus ' niger. The writer raises the question whether in the myoclonic type of the disease the centres might not be localized in the opticus thalamus transitorily. The absence of lethargy, together with the striking myoclonic convulsions, justifies the differentiation of a myoclonic type of epidemic encephalitis as distinct from the lethargic type. Relapsing Fever. — W. K. Calwell (Lancet, Octo- ber 16, 1920) studied 125 cases of relapsing fever among British and New Zealand troops in Cairo. Sixty-nine of the cases were of the North African type, the rest of the Palestine type. The former, which has been described by Sandwith and Balfour, is treated with salvarsan. The latter is often at first diagnosed as malaria or pyrexia. Fever and relapses occur to as high a number as thirteen. Afebrile periods lasted from two to twenty-seven days, and the longer the interval the rarer the relapses. Pneumonia, facial paralysis, and jaun- dice may complicate cases, but only one of fifty- six cases were fatal. General prophylactic measures should be taken ; salicylates and aspirin are used for rehef of pain ; fluid diet prescribed. Kharsavan in 0.6 grain doses is a specific largely preventing rclai^scs. The disease is tick borne. Proceedings of National and Local Societies AMERICAN PEDIATRIC SOCIETY. Thirty-second Annual Meeting, Held in Highland Park, III., May 31, June 1 and 2, 1920. The President, Dr. Thomas S. Southworth, of New York, in the Chair. ( Concluded from page 87 .) A Twenty-four Hour Schedule for Boys. — Dr. Richard M. Smith recalled that in a previous com- munication he drew attention to certain funda- mental principles with reference to the care of the health of school children, and pointed out lines for the further extension of health supervision. A table had been prepared showing the proper distri- bution of the boy's time during school hours be- tween study, activity and inactivity. They were now convinced by a further use of the table that it gave a correct distribution of the boy's time. The parent, the physician, and the teacher were together responsible for the child's life, and no part of that life could be arranged intelligently without the cooperation of all three individuals. For in- stance, the child's physical environment, such as buildings and fresh air, was dependent, not only upon the proper sanitation of the school building, but upon the room he slept in. His nutrition was maintained not only by the school lunch and the dinner received at school, but also by the breakfast received at home. His. educational work in school must be arranged, bearing in mind not only the studies necessary for the school curriculum, but also whether or not he was doing work at hoine, such as music and languages. His exercise was made up of what he did at home in the afternoon quite as much as of the carefully arranged athletics at school. A Study of Breast Feeding in the City of Min- neapolis. — Dr. Julius P. Sedgwick, of Minne- apolis, described a plan to encourage breast feeding that he had been instrumental in putting into effect in Minneapolis. The work fell into two parts : 1. That of maintaining breast feeding. In their private work and in the clinic they had been using certain principles described in a paper presented before the American Medical Association in 1917 for maintaining and increasing the supply of breast milk." They wished to see if these principles could be applied on a larger scale. 2. They wished to ascertain what statistical results they could show by a wider application of these principles as to the proportion of mothers nursing their babies and the effect on infant mortality. In order to maintain and promote the milk supply they had used the well known methods, paying special attention to that of making a demand upon the breast by expression. This he felt was the most important factor in main- taining the supply of breast milk, and had enabled them to accomplish a great deal. The technic used in the expression of the milk was not that of going over the whole gland tissue and using massage, but simply consisted of emptying the sinus back of the colored areola. Expression was used for premature infants, where the mother had poor or inverted nipples, sore breasts, or, if for any reason tiie baby could not take the breast and they wished to main- tain the milk supply. The other part of carrying out their plan con- sisted in reaching the public. This they had done by gaining the cooperation of the medical profes- sion, the health department, the Infant Welfare Society, and that of prominent citizens. The mother of every baby born in Minneapolis during the year was either seen by a representative of the organ- ization or reached by mail or telephone. Each mother was given information and literature. She was followed and seen or heard from every month or oftener if necessary. As a result of this work ninety-six per cent, of the babies born in Minne- apolis were breast fed, and the mortality had dropped from seventy-one to sixty-five per cent, for that year. The Fate of Subcutaneously Injected Red Blood Cells. — Dr. Rood Taylor, of Minneapolis, stated that former experimental work had proved that subcutaneously injected red blood cells were quaHtatively capable of reaching the recipient's cir- culation. In this work the usual clinical methods were employed to show that the subcutaneous injec- tion of large amounts of homologous citrated blood into infants produces a decided hemoglobin increase. Using Ashby's m.ethod of differential red blood cell counting, the writer then determined that following subcutaneous injection of homologous citrated blood there was no marked absorption of injected cor- puscles into the recipient's circulating blood. The Circulatory System in Nutritional Dis- turbances. — Dr. W. McKiM Marriott, Dr. H. McCuLLOUGH, and Dr. K. Utheim, of St. Louis, prepared this contribution, which was presented by Dr. Marriott. He stated that in that particular nutritional disturbance known as athrepsia or maras- mus, it was very evident clinically that some changes in the circulation had occurred. This was recog- nized by the low surface temperature, slow pulse, and grayish color of the skin. It had seemed de- sirable to estimate quantitatively the degree of cir- culatory changes and, if possible, to determine the cause of the changes. In measuring the circulation they had used the colorimetric method of Dr. G. N. Stewart. Before applying this method to infants they had applied it to animals and compared the results with those obtained by the Ludwig-Stroh- niiihr. The method was easily applied to infants. In a series of twenty-nine normar infants the aver- age flow of the blood was 17.2 c. c. to the 100 c. c. of arm a minute. In applying the method to thirty-five athreptic infants the volume flow of the blood was found to be greatly diminished, some- times being as low as one or two c. c. a minute. As these infants improved the volume flow of the blood increased, in some instances becoming normal. The next question was in regard to the cause of the decrease in circulation. One cause of diminished volume flow of the blood was known 132 I'ROCBEDIXGS OF NATIONAL AND LOCAL SOCIETIES. [New York Medical Journal. to be a decreased blood volume. The next step was to determine the blood volume of normal and athreptic infants. In a series of normal infants the average blood volume was 9.1 per cent, of the body weight, the variations being from 8. to 10.8 per cent. The average blood volume of a number of athreptic infants studied was eight per cent, of the body weight. One showed as low as 4.8 per cent. As adipose tissue is a relatively non- vascular organ, none would expect a thin infant to have a larger amount of blood per kilo of body weight than a fat one. They found the reverse to be often the case. This indicated definite de- crease in the volume of the blood. The lowered tdood volume was sufficient to account for the low volume flow in at least some of these infants. Other factors, however, seemed probably to be operative. The peripheral volume flow of the blood would be increased if capillary or arteriolar con- striction had occurred. They found such a constric- tion to occur in these mfants. This was shown by the fact that there was a piling up of the blood corpuscles on the capillary side. Blood obtained by a prick in the skin of these infants showed a distinctly higher hemoglobin in red and white cell counts than blood obtained directly from the veins. This constriction of the arterioles leads to poor peripheral circulation and probably to the gray color of the skin. They considered the arteriolar constriction as a compensatory mechanism to maintain blood pres- sure when the blood volume was diminished. They found this mechanism ordinarily sufficient to maintain the blood pressure as they very rarely observed low blood pressures in the athreptic in- fants studied. Having considered the changes in the blood and in the vessels, they next turned to a consideration of the heart muscle itself. This, as might be expected, would atrophy with the rest of the body, but at postmortem very little change in the heart muscle could be made out. It is pos- sible, however, that functional changes might occur. To determine whether or not such was the case, electrocardiograms were made, and in a certain number of the infants definite changes in the functional activity of the heart muscle were demon- strated. The variations from the normal most frequently observed were low amplitude of all waves. With improvement in the clinical condition of the patients the form of the electrocardiograms changed and this suggested that the alterations in the heart muscle were functional rather than organic. They suggested that poor circulation through the coronary arteries was in part responsible for the changes, a vicious circle being thus established. Some experiments were done on animals in an attempt to reproduce the athreptic condition. After a period of complete starvation the blood of rabbits was found to be definitely decreased, and also the volume flow. When the animals were again fed they maintained a constant weight for a consider- able period of time until the blood volume slowly increased. After this the process of repair became more rapid. In some animals the blood volume did return to normal, and these animals failed to recover their weight and finally died. The Calcium Magnesium Phosphorus Balance in Children Subject to Convulsive Disorders. — Dr. B. Raymond Hoobler. of Detroit, presented a study of a group of children subject to convul- sive disorders, none of whom gave a history of epilepsy in the family. Normals of the same age and weight were used as controls. The balances for phosphorus, calcium and magnesium were deter- mined. In general, it was found that the retention of these minerals was considerably diminished in children subject to convulsive disorders, though in no instance was the balance lowered in all three. In convulsive disorders of this type a search should be made for some mineral deficiency, either in calcium, magnesium, or phosphorus, and if such a deficiency is found an attempt should be made to bring it up to normal. Electrocardiography in Children. — Dr. AIax Seham and Dr. Frederic W. Schlutz, of Minne- apolis, presented this paper, which covered the physiological peculiarities of the normal electro- cardiograms of children of all ages, including the premature, from one hour to thirteen years ; the pulse periods in fiftieths of a second in all ages ; the transmission time of both auricle and ventricle, and electrocardiograms in diseases peculiar to child- hood. The electrocardiogram at birth was found to be constant, all the newborns, twenty-two in num- ber, showing constant curves. A right ventricular preponderance was characteristic, showing a deep S and a high R^. This form persisted during the first three months. During the fourth month the S became smaller than the R in Derivation 1, sig- nifying a change from right to left ventricular preponderance. From the fourth month to the end of the first year it gradually changed to the adult type. From the first year on the adult charac- teristics persisted. In the premature the form of the electrocardiogram was incomplete. All of the deflections with the exception of S were not seen. The pulse in newborns was regular, as shown by electrocardiograms. Sinus' arrhythmia was not complete until the school age. From this time until puberty it occurred in about fifty per cent, of nor- mal children. By measurement of the P-R and R-T intervals the transmission time could be accu- rately studied. The average P-R in the newborn was 0.10 of a second; from two to five years it was 0.12 of a second, and from six to thirteen years it was 0.28 of a second. This included the Q-R-S period, which in the respective ages was from three hundredths to nine hundredths of a second. The electrocardiogram was likewise of great aid in the diagnosis of abnormal conditions. A study of twenty-two cases of congenital heart lesions, two of which came to autopsy, showed that only in cases in which the right side of the heart was involved, especially in pulmonary stenosis, was there a characteristic right ventricular preponder- ance. In seven of eleven drop hearts, all of which were confirmed by x ray, the ventricular complex in lead one was unusually low. Three hundred cases were studied, including those showing the exudative diathesis, decomposition hypertrophy of the heart when unassociated with heart murmur, spasmophilia, or tuberculosis of the lungs. New York Medical Journal INCORPORATING THE Philadelphia Medical Journal ;t Medical News A Weekly Review of Medicine, Established 18Ji.3. Vol.. CXI!!. No. 4. Ni:\V VoliK. SATURDAY. .lAXrAUY 22. 19:21. Whole No. 2109. Original Communications MODERN COMMENTARIES ON HIPPOCRATES. The Pneuma and the Books of the Hippocratic Corpus. By Jonathan Wright, M. D., Pleasantville, N.'Y. In approaching the question of doctrinal indica- tions in the works of Hippocrates from the view- point of their historical development, I am embar- rassed to find myself confronted by the ciuestion of the authenticity of the separate books. In previous articles dealing with the theory of the pneuma, I have committed myself to the belief that the dia- logues of Plato and the works of Aristotle were written before many of the treatises found in the various editions of the Hippocratic Corpus. I find myself quite incompetent to judge, not only of the value of much which Galen has said about the sub- ject, but especially of tiie value of the many paleo- graphic, philological, and archeological arguments advanced by writers in less remote periods, from Tiis times to our own. I have been guided chiefly by Littre as to what are the genuine and what are the spurious works, since all the works, at one time or another, by one editor or another, for one reason or another, have been ascribed to the authorship of Hippocrates II, son of Heraclides and Phsenerete, .^ui^posed by most authorities to have been born in Cos about 460 B. C, but by some writers asserted to have lived at an earlier or a later time than this would indicate. The length of his life and the place lit his death are involved in still greater doubt. There is hardly a treatise of them all which has not liien declared of doubtful origin, and even the most commonly discredited tract has rarely a surer claim to any known successor or predecessor for its origin. Despite my own helplessness, I confess I am not always filled with implicit trust in the judgment of the great French savant, whose work, now more than three quarters of a century old, is by all odds the most trusted. Unable to judge of the weight of many of the arguments advanced by the critics, nevertheless I have allowed myself to be influenced by those which seem to me capable of impressing the casual reader. •Accepting the date 460 B. C. as that of the birth of Hippocrates, that of Plato as 430 B. C, that of Aristotle as 384 B. C, we are justified in believ- ing that any outstanding anatomical fact known ta Hippocrates, it would seem, was known also to the latter two. The acquaintance of Plato and Aristotle with the knowledge of their times and their works, which have come down to us. were so extensive and of such a character it is impossible, apparently, that it would not only have been known to them, but improbable that they would have passed it over in silence. It is not true, as we would infer from some histories of medicine, that in the genuine works of Hippocrates there is no mention of the artery in apposition to the vein. The word does occur in Articulations, a book undoubtedly genuine, and refers to a bloodvessel, but there is no indi- cation of anything but a nominal differentiation from a vein. In Plato and in Aristotle, so far as I know, the name artery as indicating a bloodvessel does not occur. I do not know how to account for this. Galen says that Euryphon, a Cnidian older than Hippocrates and of course something like a hundred years before Aristotle, made the distinction, although Wellmann thinks Diodes, a contemporary of Aristotle, first made it. I cannot see much plausibility in the suggestion that where the name occurs in a genuine book like Articulations and in other treatises, supposed to be citations from some of the genuine books, although written perhaps by authors contemporary with Aristotle, it is the inter- polation of a copyist. There is a similar difficulty, too, with the word muscle. Both artery and muscle are mentioned in books, which in no way, other than the names, refer to anything indicating a discrim- ination of the former from other bloodvessels or of the latter from other flesh. If we find in Aris- totle no mention or no explicit discrimination be- tween artery and vein, we cannot but believe that the Father of Medicine, much older, was also in ignorance, and that the passages in his writings containing such mention are spurious. These three men furnish us with the most exten- sive and the most exhaustive (I was going to say with the only) account of the philosophical and the medical theories and facts, extant in the Greek world from the birth of Hippocrates, through the life of Plato to the death of Aristotle, and there are some facts, one would think, to which not one of them would have failed to allude, if known to him. The separation of the artery from the vein is one. I cannot see that Galen takes any account of this chronology in his discussion as to the authenticity of certain books of Hippocrates. There are other facts which have been adduced against the validity of the only example I have here Copyright, 1921, by A. R.. Elliott Publishing Company. 134 IV RIGHT: COMMENTARIES ON HIPPOCRATES. [New York Medical Journal. introduced of this critical discussion, which since Galen's time has centered around the question of the authenticity of the separate Hippocratic treatises. As to the definition of artery and vein, I have thus far broached the subject because in the previous paper, more particularly concerned with Aristotle, we also came squarely against it in the statement of his knowledge of the ultimate bronchial divisions and the pulmonary circulation. We saw how vitally involved was his doctrine of the pneuma with the anatomical relation and the physiology of the great vessels. We must think he surely would have said more, if more had been known to him. Yet Littre . can find no argument against the greater knowledge of Hippocrates. If I have exposed sufficiently a point of valid criticism of a kind constantly met with in the writ- ings of those who have commented on Hippocrates, I may be permitted to point out another which, on the other hand, is sometimes given more weight than it deserves in the literature of the subject. There are two kinds of men who gain recognition in scientific medicine; indeed, I suppose, in other branches of science also. In fact, the types are recognizable in walks of life which are not scientific at all, and though we are not primarily concerned with these the conventional idea of that form of group leader who tells people that which they wish to hear and are capable at once of understanding, in the way of illustration, will serve us well enough. He floats with the tide, he turns his sail to every favoring breeze, however temporary. His weather vane points, not necessarily to the horizon of truth at all, but, mindful of the opinions of bis fellows, to that part of it from which the wind of popular interest is blowing. This political huckster is the type of the man of science who is concerned only with propagating self evident truths or already widely held beliefs. He does this with an assurance that amounts often to insolence, but he founds no new ones. He is the champion of the obvious or the apparent, of the pneuma or of any prevailing fad today — it is better to let the reader fill ,in the name of that himself — but in his defense it should be said that he, too, has his usefulness in his profession, whatever it may be. With industry in it he reaches the summit of that kind of ambition which he has been able, from his mental limitations, alone to nourish. His exhortations and dissertations are largely reflex, he thinks with his spine, the product is the reflection of the mass in which he is immersed. From such an individual issued some of the books of the Hippocratic Corpus. On the contrary, in others, however far from the truth we may know the author to be, we note Hip- pocrates carefully, painfully, modestly weighing the evidence pro and con — experience is misleading and judgment difficult — the doubt which bespeaks the occupation of a mind too absorbed with the problems of life to exploit its commonplaces in the interest of his fame is found on every page. Not by any means on every page, but now and again we get a flash of light that shines across the ages. The good the other man does lies buried with his bones. We meet him so often in the Hippocratic Corpus only because some Alexandrian captain of marine industry has foisted his writings on the librarian by bluff as the work of the great Hippocrates (6). Now it is quite impossible for the diligent and intelligent reader, as the work of Hippocrates is , transmitted to us, not to be struck with thoughts like these, but he should beware of setting them up as a canon of criticism. They but reflect his own limitations. I have not infrequently seen some of the aphorisms of Hippocrates lauded to the skies by men whose common sense I am occasionally compelled to respect, which I regard as an insult offered to the understanding of the Father of Medi- cine, either as a 'physician or as a man of sense, but I recall how often I have had occasion on the other hand to think a thing pretty good which a critic, vastly more learned than I, considered be- neath the intellectual powers of Hippocrates him- self. Nevertheless, it is a fact that in most of the books, which from other internal and external reasons are supposed to be genuine, we find the theory of the pneuma and the theory of the humors but casually mentioned and cautiously applied, or, as in Ancient Medicine, subjected to a raking criti- cism which must have seemed cranky and perverse to the good mixer who wrote the Winds or the Humors. 1 sometimes wonder if this wide extended hetero- geneity is not responsible for some of the fame of Hippocrates. It appeals by virtue of it not only to the man of science but to the man of the street, not only to the philosopher but to the fool, not only to the selfcontained philosopher but to him whose sphere of usefulness is the propagation of the work of more original men. Every advance in knowledge which can, by popular agitation, be im- pressed on the people owing to the simplicity in the processes of thought involved, to the earnestness with which it is urged, or to the manifest advan- tages derivable from its application, is sure, because of these things, to pass through an epoch of gross exaggeration and distortion, both in discussion and in the deductions made from it. The application of the latter in practice is usually carried to ridicu- lous extremes, as it doubtless was at Athens when Aristophanes was writing The Clouds. Oblivion and neglect of the kernels of truth such a fad often contains are then the regrettable consequences of this hotbed forcing of a medical belief, based on halfbakecl theory and insecure facts, and urged with all the arrogance of those who derive their beliefs from the authority of. others rather than from their own resources of thought and action. Let the reader turn to the tract on the Winds or the Pneuma — the winds without, the pneuma within the body. Its subject is the fresh air fad of Athens in the time of Hippocrates, having been ascribed to Diogenes Apollonius, or, perhaps, if at a later period, it may have been written in that era of Alexandrian research when the great wave of new facts was sweeping over the world of ancient philosophy and annihilating its poise of intellect. From what I iiave said above the reader will easily understand why no critic loyal to the art is eager to fasten the authorship of it on the Father of Medicine. January 22. 1921.] Jl- RIGHT: COMMENTARIES OX HIPPOCRATES. 135 "All maladies are gf the same nature ; they differ only in their location. . . . However, there is never but one form and the cause is always the same. ... I am going to show that all diseases liave their origin and proceed from (the pne^ma) . . . fever . . . inflammation . . . colic . . . bellyache ... all are caused by the passage of the pneuma . . . flux not only of the bowels but of the lungs — hemoptysis . . . ruptures . . . dropsy . . . apoplexy . . . epilepsy — in fact the winds are the chief factors in all diseases" — the air outside the body — the pneuma within. That is the skeleton outline of an obsession which, I suspect, followed the study of aerial phenomena successive to the demonstration by Empedocles of the materialistic nature of the air. I conjecture this book, though not by Hippocrates himself, may have been of the Hippocratic era because the theory of the scientists of the Nature Philosophy was impressed at this time on the fickle and fun loving Athenians by Anaxagoras, and probably by Diogenes Apollonius, both of whom seem to have incurred the animosity of the people. How much of this was an outcome of, or how much resulted in, the savage ridicule Aristophanes cast upon Socrates and the sophists we can only conjecture. We see him making fun of the vortex of the atomic theory specifically. The air monism of Anaximines we see exciting his ridicule, but it was misdirected when applied to Socrates, who in Plato's portrayal, him- self jeers at Anaxagoras and Heraclitus. Socrates was pilloried by Aristophanes in the Clouds or hung as near them as possible on a high wall on the stage, sniffing the pure air, and he as well as all the players were endowed with long noses so they could sniff up as much of it as possible. A generation ago a daily paper in New York, with large headlines, in jovial humor, drew atten- tion to the inference to be drawn from the enthu- siasm of a young niedical author who had pointed out the filtering and warming and moistening of the inspired air in the physiology of nasal respiration. The wit of the press relieved the tedium of scientific argument by discoursing on the advantages of having a long nose. Doubtless the reporter was innocent of any knowledge of Aristophanes's old joke, but he anticipated by a decade or so that era of faddism on the subject of fresh air which has suffused popular science since, and which has to some extent obfuscated that of the hierarchy of science itself. To some such era as this I 'am dis- posed to think we may venture to ascribe the pub- lication or the composition of this Hippocratic book on the Winds. The author evidently had to meet some criticisms as to the morbid manifestations of the pneuma. "Why," they will ask me, perhaps, "are not all animals affected by it? Why do these diseases attack one case?" "Because," I would reply, "body differs from body, one kind of nature from another, one kind of food from another. For the same things are neither always alike suitable or harmful to every kind of an animal ; some work weir, some work evil." Introducing thus a host of additional etiological factors he seems unaware of them. That one thing, the pneuma, dominates his whole mentality. He uses a word familiar to us, but he docs not even think of bacteria: "When the air is infected with miasms, which are hostile to mankind, men become sick." Then, becoming em- barrassed, how natural it is to find him taking refuge in mere tautology. "When, on the contrary, the air is unsuitable to some particular kind of animal, it is that kind of beast which is struck." The pro- fundity of this remark is quite modern as well. It is a sense of humor that is lacking in us when we talk like that. The Regimen in Acute Disease is attributed both by Galen and by Littre to Hippocrates, but the appendix, according to both, is by a later and a weaker hand. In it we find in several places a reference to an etiology which includes the stoppage of the air in the veins. Some disorder of the humors, some lack of equilibrium, perhaps, in their qualities or quantities, is the prime factor which works on the system through interference with the pneuma. In The Sacred Disease, not usually ascribed to Hippocrates himself, though Adams in- cludes it among the genuine works, but evidently if not his the work of a disciple better grounded in anatomy, we get a conception which is in the direct line of inheritance from the one in the Papyros Ebers. "By the veins we take in the greater part of the air, for they, too, are the breath organs of our body, which carry into us the air. They distribute it everywhere by means of the little veins, then they exhale it, having thus brought in- vigoration." This I think is undoubtedly a trace of the doctrine of the transpiration through the skin which we find elaborated in one of the fragments of Empedocles, but I do not know why Wellmann should attribute to the latter the statement that epilepsy arises from a change in the winds. To Alcmaeon we with better reason may attribute the teaching insisted on in this book that the brain is the seat of the intelligence. We may see in these things the influence of the Sicilian School, but it is made extremely doubtful by Littre that this tractate is to be considered as coming from the hand of Hippocrates himself. It is not at all sure from anything we can find in those books, more surely genuine, that he actually shared this idea of Alcma;on about the brain, though he did undoubtedly share in the conception of Alcmseon's which looks upon disease as a loss of that equilibrium in the elements which obtains in health. This very popular idea was associated with that of beauty or symmetry of form not only by Plato but by the Stoics and many centuries afterward by Galen. It had such a wide affiliation with geometry and the science of number and with the fundamental tenets of the Greek theory of art that we are scarcely warranted in thinking of Alcmaeon or of any other Greek, however early, as originating it, but we cannot yet trace further back than Alcmaeon the correct notion as to the function of the brain. We ^may suspect the simile of an equilibrium as the state of health came like the pneuma from Egypt but not the local- ization of the cerebral functions in the brain. In the Nature of Man, one of the spurious Hip- pocratic books, according to Littre, we again find a statement which implicates both the pneumatic and the humoral theories in the explanation of diseases 136 ir RIGHT: COMMENTARIES ON HIPPOCRATES. [New York Medical Journal. which "come, some from the diet and the manner of the diet, others from the air," — from the latter those diseases we call "epidemic." To this word in the Greek no suspicion of infection or contagion as yet attaches. It was a loose term equivalent to the prevailing diseases. The // Epidemics, which seems to be made up from extracts from other books in the Corpus, some genuine, some spurious, and the Aliment, with which I have dealt elsewhere, speak of the air as a food. Littre's comment on this is that this conception involves that of varia- tions in the air giving rise to disease as do variations of the food in the digestive tract, the air acting on the respiratory passages and upon the blood vessels, both of which take it in. In the book on the Nature of tlic Bones, and also in the little tract on the Heart, we get further hints of an anatomy originating with that of the Papyros Ebers, but nevertheless in both books we perceive a decided advance over the anatomy of the supposed genuine books of Hippo- crates. In the latter there is a similarity in the conception to that adopted by Aristotle. In resume of the series of essays in which this belongs, I may .say I have drawn attention ( 1 ) to the ideas of that typical primitive group who stood around the dying savage. In every ethnic origin that scene was enacted, and the impressions made on the mind of man became the possession of them all. It was the breath which was the animating soul of man. It led the materialistic Egyptians (2), the more or less direct heirs and to a large extent the descendants of the African tribes with whom they had always been in contact, to the conclusion that the pneuma, in order to accomplish its mission, must penetrate to the uttermost ramifications of structure in the animal framework. As there were demonstrably channels through the nostrils and buccal cavity to the chest, so these channels and their communicating branches must lead the pneuma to the contracting finger or the marching foot, to the beating heart and the gastrointestinal tract, rumbling in the abdominal cavity. The mummy maker found many channels: the trachea, the blood- vessels ; many cavities : the heart, the bladder ; many tubes : the hepatic, the renal, the openings of the nasopharynx, through one of which passes the breath of life and through the other the breath of death; the anus, through which passed the flatus and the feces. You could feel the pneuma beating in the heart and in the bloodvessels wherever the hand was laid on them. You could hear it in the bor- borygmi of the stomach, and bowels, and in the respiratory sounds. We are at the present time more able than formerly to be assured how these thoughts were exchanged throughout the civilizations which bor- dered the IV^cditerranean Sea. Plato and Solon traded in oil with Egypt; Pythagoras, Herodotus and Democritus, and many others, travelled there. Political exiles fled across the sea from one con- tinent to the other. Prehistoric commerce and con- quest evidently went on for thousands of years before Hecataeus wrote, and before the pages of Herodotus were filled with the Greek characters which have been preserved for ;.is. It is supposed by some that the Berlin Papyrus, a transcript of notes from the Ebers manuscript, and others, was known to (ialen. The anatomical learning, which was stored beneath the feet of the god Anubis five or six thousand years ago, surely passed into the Greek world, and the germs of philosophy, already alive in the more ancient civilizations, were the in- heritance of the nature philosophers on the Asiatic shores and the ^gean Islands. The enormous expansion these received from the later Greeks has been the wonder of the world ever since. Out of the Egyptian fermentations grew many ideas found in the Homeric poems. The Poem of Gilgamcsh, in- calculably older, the Rig Veda, perhaps contem- porary, the Zend Avesta, all contributed their fructifying waters to the ocean of human thought spread out in the annals of the golden age of Greece. We have found (3) in the Iliad and the Odyssey that conception of the soul, which is identified with the air or the pneuma and which is essentially that of primitive man. We have seen it appearing under modified forms here in several of the later books of the Hippocratic collection, and we have also seen it idealized^ by Plato (4) and accepted by Aristotle (5). In broad outlines they all led naturally to the evo- lution of the two leading doctrines which dominated the science of medicine for thousands of years, but Hippocrates the Great was not led away from realities by them. Both pneumatist and humoralist theories survived the pressure of new anatomical facts, revealed by the Alexandrians, for more than fifteen hundred years. It necessitated another on slaught of anatomical revelations slowly and surel to banish these particular blights of theory, in thei ancient aspects, from the path of progress, but they still can be found under other forms hidden in modern theory, yet not in theories alone as obstruc- tion to new knowledge, but as founded on facts valid, as we believe. BIBLIOGRAPHY. In the preparation of this paper the following sources were used for reference to the works of : Hippocrates: The translations of Francis Adams: H-h- pocrates, Genuine Works; E'Littre : Hippocrates. Oeu: res Completes. Galen: Chutdii Galeni Opera Omnia (Kiihn). Aristotle: History of Animals (tr. Bohn) ; Treatises, translated by Thomas Taylor, 1805. REFERENCES. 1. Blood and the Soul. New York Medical Journal, July 20, August 10 and 17, 1919. 2. The Blight of Theory. Ibid, December 7, 1918. 3. The Theory of the Pneuma in Homer. Ibid, May 22, 1920. 4. The Anatomical and Physiological Theories of Plato. Ibid, July 3, 1920. 5. The Theory of the Pneuma in Aristotlt^. Ibid. Xo- vcmber 27, 1920. 6. Modern Commentaries on Hippocrates. Ibid, De- cember 13, 1919. ' \Vc know of Plato's tripartite division of the soul. In the latros, (loul)tless wrongly ascribed to Galen, the pneuma may be found .split in thr.e divisions likewise. Jaiuiary 22, 1921.] HIGH MAN: TREATMENT OF ACNE. 1.^7 THE MODERN TREATMENT OF ACNE. By Waltf.r J. High. MAX, M. D., New York. Until recent years acne has been one of the most bafifling skin disturbances to treat, and at the same time one of the most serious to leave unimproved. This does not imply that the condition is organically grave, but it is prone to attack young individuals during the age of courtship and, because it is so disfiguring, it throws upon the sufferer an unwhole- some burden of selfconsciousness. Therefore, from the viewpoint of human psychology, it constitutes a handicap far in excess of the trivial organic damage it does. Its effects accomplish this during its active stage, and it is particularly disadvantageous to' young women, often inducing in them a state of mind approaching melancholia. After the active phase is over, the permanent damage done to the skin is sufficient to perpetuate in a mild degree the mental suffering occasioned during its earlier stages. There- fore, the problem of treating acne is important, not only because an organic disease must be controlled, but because a condition predisposing to subjective disturbances is presented. Acne begins just before or during the onset of puberty, and is characterized by an increased oili- ness in the skin, the formation of hyperkeratotic plugs in the follicles, and a general subtle sallowness. The plugs alluded to are called comedones, and these are the starting point of the pustules which in turn furnish a further disfiguration. Accom- panying these skin changes, which are mainly present on the face, chest, and back, are scaling of the scalp, and sometimes loss of hair. Associated general manifestations are gastric indigestion, usually most pronounced as to starches and sugars, constipation, slight enlargement of the thyroid gland, coated tongue, and, depending upon the character of the individual, .selfconsciousness and even melancholia. It is probable that the subjective manifestations are more likely the result of the eruption than of the underlying causes thereof. In women the eruption often grows worse in relation to the menses. Not uncommonly an in- crease of sugar is found in the blood, and the gastric contents show a high percentage of acidity with markedly increased free hydrochloric acid. An analysis of the entire picture reveals the following: The skin tends to scale, the 'sebaceous glands en- large and secrete excessively, and the secretion can- not drain off l)ecause the plugs in tlie follicles interfere. The underlying causes of the disease are probably associated with the profound changes inherent in puberty. Inasmuch as puberty cannot be hurried or modified by treatment, the main hope of therapy lies in an attempt to alter the skin so that the pre- disposing features become unable to do any great damage. It is necessary, before continuing, to state that the formation of pustules is incidental, the comedones acting as foreign bodies which make it possible for the bacteria in the follicles to become active. Thus the indications for treatment are twofold: First, the prevention of comedone forma- tion ; second, the control of the underlying factors, where this is possible. Incidental indications are the treatment of the scalp and the expression of the pustules and comedones. The general treatment consists of regulating the diet by cutting down the starch and sugar intake and by promoting intestinal function. The latter is best accomplished by eating green vegetables and stowed fruits, together with the judicious use of cathartics, if indicated. If there should be a dis- turbance of the internal generative organs, a con- dition rarely found in the young, this should be controlled. In dieting patients, however, it is ex- tremely important to keep up the general nutrition and weight. The most important indication in local treatment is to prevent comedone fonnation. If this can be accomplished, pustules will not develop and the disease will be automatically controlled, even though the predisposing causes are not, for acne cannot occur where the skin is normal and the sebaceous glands are not overactive. In former days this was done with moderate success by the use of sulphur, resorcin or salicylic acid in lotions or creams. These substances make the skin peel and tend to overcome the condition favoring acne. Today this may be accomplished more certainly and more precisely by the use of the x rays in given amounts. One Holzknecht unit applied to the face weekly, for from ten to sixteen expo.sures, will cure the average case of acne, and if from time to time there .should be recurrences, these will yield readily to two or three exposures. The x rays work by diminishing the function of the skin glands and by diminishing exfoliation. Conservatively stated, nine cases out of ten can be cured in this fashion. Thus it is possible to start treatment when acne first appears and before any real damage has been done to the skin. No local treatment is neces- sary at home. This eliminates the expense and the loss of time that the purchase and application of drugs involves. In other words, about six minutes weekly in a physician's office for from ten to six- teen weeks will accomplish more than older methods could ever do. The cosmetic result is enhanced by :>killful ex- pression of the comedones and pustules, and the incidence of recurrences is reduced by the use of mild antiseptic lotions to the scalp. The employ- ment of vaccines, so far as my experience goes, promises nothing, for, as already stated, the pus- tules are purely incidental and will not develop unless comedones are present. It goes without say- ing that the general treatment should not be neg- lected, for, after all, the disease is a local mani- festation of a general disturbance, and more perma- nent results are secured by bearing this fact in mind. Nevertheless, without the local disturbance, the general derangement is incapable of producing acne, so that the major indication is the treatment of the skin. In addition to the foregoing, the patient should wash the face with a rich lather twice a day and shampoo once a week with some simple soap. Green soap is contraindicated. Recurrences take place in about one case in four, and are easy to control with two or three x ray exposures. This line of 138 ROSENHECK: NEUROLOGICAL BACKACHE. [New York Medical Journal. treatment was unsuccessful in only three instances out of fifty, and in one of these patients there was a marked secondary anemia. Such exceptions are indeed rare, and as compared with older methods of treatment, the precise one outlined removes acne from the group of the serious disturbances of youth. 780 M.ADisox Avenue. BACKACHE DUE TO NEUROLOGICAL CONDITIONS.* By Charles Rosenheck, M. D., . New York, Neurologist to the Hospital for Deforrnities and Joint Diseases, New York, and the New York Diagnostic Clinics. Backache as a distinct neurological manifestation holds a subsidiary place in neurological afifections. On account of the anatomical proximity of the back muscles to the spinal cord the natural presumption would be that this symptom would at once obtrude itself in the clinical picture as a major symptom. The contrary, however, seems to be the case. An analysis of the functions of the spinal axis readily explains this seeming paradox. Its activities, both motor and sensory, are in the main projected at a distance from its anatomical location. Pain as a s}Tidrome of sensory disturbance is therefore propa- gated along distal pathways, although the situation of the anatomicopathological lesion is proximally located. One must not, however, accept this rule as a finality. Distinct anatomical differentiation is an essential which is not to be ignored in our analysis of the pain syndrome ; for it is a fact known to the veriest tyro in medicine that an implication of the posterior* spinal root or its ganglia is neces- sary to propagate the painful sensation to distant anatomical parts. A different view, however, is permissible when the dural covering alone is in- volved. As far as clinical and experimental data are available, pathological processes here do not call forth painful sensations at a distance. On the con- trary, the immediate anatomical structures reveal the effect of dural disease; hence we find as a major symptom of spinal meningeal affections, se- vere and persistent pain in the musculature of the back. Backache as a symptom in diseases of the spinal cord has evidently been treated rather lightly by medical, writers ; for in a thorough search of the available literature I was able to find only two ar- ticles on the subject which approached it from the viewpoint of the neurologist. These were by Lang- don and Neustadter, who built up their clinical neurological picture on the patient's chief complaint of backache. One can readily appreciate why this symptom has escaped the attention of our vol- uminous medical writers. After all, it is only a minor complaint and is readily submerged in the far more striking picture of gross motor and .sensory disturbances. These defects are more dis- tressing to the patient and wholly dominate the clinical . picture. Incidence. — In an analysis of the clinically recog- *Rcad at a nie;-tiiiR of the New York Physicians' Association, November 23, IP-'d. nizable afifections of the cerebrospinal axi.s, taken from the standard textbooks of Starr, Gowers, Op- ])enheim, Osier, Dejerine, Strunipell and \'on Leube. backache as a symptom occurs in thirty per cent, of all neurological conditions. This is surely not an imposing figure. Obviously it could be in- creased greatly if we were to limit our analysis to affections of the cord per se. Under this scrutiny we will find this symptom as a subjective complaint, in all affections of the spinal axis where we can definitely establish the etiological relation to hemor- rhage, acute inflammatory disease, and new growths. Here again the necessity of reiterating that it plays a subsidiary role in the symptomatology is permis- sible. It is the gross motor and sensory manifesta- tions in these affections that at all times control the clinical scene. Etiology. — The etiological factors involved in the causation of backaches in neurological affections is to be looked for in those morbid processes which at once affect the integrity of the dural covering and the dorsal roots. In the main these are to be found in acute or subacute infections of the meninges, hemorrhage in the cord substance or its dural cov- ering, and neoplastic processes. Degenerative dis- eases of the spinal cord may cause backache, but the pain in these affections is insignificant and must be explained more on the ground of interference with the patient's . motor activities. Inflammatory processes in the dorsal roots and ganglia which manifest themselves clinically as herpes zoster will quite often be preceded by severe back pains: Traumatic neuroses and neurasthenia are particu- larly prolific in producing pa,inful and persistent backache and are worthy of special mention. The underlying pathology in these affections is quite obscure and has been the subject of much con- troversy. Under traumatic neuroses, the railwa}' spine of the older writers, notably Erichsen, held full sway. This observer regarded the condition as the result of inflammation of the meninges and cord. Walton and J. J. Putnam were the first, how- ever, to recognize the functional nature of many of the cases. To Westphal and his pupils we owe the name traumatic neurosis (Osier). Quite re- cently the appellation traumasthenia has crept into the literature and this to my mind aptly describes the condition. It is not an exaggeration of fact to say that in contrast to the insignificant role that backache plays in orgdnic affections of the nen'ous system, the contrary holds true in the traumatic neuroses. It is easily the major presenting sub- jective symptom in a great number of cases.. The imderlying etiology varies with the individual case, but in the main trauma and the resultant shock to the nerv^ous system are the factors involved. Of course great caution must be exercised in insisting on the functional nature of a given case, for trauma and shock can be so severe- as to seriously com- promise the integrity of the cord and meninges. Organic changes are the inevitable results and our interpretation of the resulting sensory and motor phenomena inust be considered in the light of an- atomicopathological disturbances. The backache of neurasthenia has been observed by clinicians since time out of mind and the well known spinal irri- January 22, 1921,] ROSENHECK: NEUROLOGICAL BACKACHE. 139 lability of the older writers has tlchnitely ])Ut a stamp on this affection to the present day. The etiology of this back pain, apart from the ev,er fas- cinating theory of chemicophysical changes in the spinal cord, is most likely due to a generalized neuromuscular fatigue. Pathology.— The pathological processes which cause back pain obvioush- var}- and are determined by the underlying conditions. Broadly speaking, these are hemorrhage, inflammatory afifections and new growths. Any one of these morbid states can readily aflfect the integrity of the dural membranes, spinal roots or ganglia. In simpler terms, pressure phenomena or inflammatory reactions in the spinal axis are responsible for the pathology of back pains. It is unnecessary to dwell at length on the histo- pathology governing these processes. Thev are selfexplanatory and need no further elucidation. Neurological co)id!tioiis producing backache as a symptom. — In order that this s}-mptom may receive its proper evaluation it will be necessary to enumer- ate again the morbid processes affecting the spinal axis in which back pain is a subjective complaint. These in the main are acute and subacute inflam- matory diseases, hemorrhage, new growths, degen- erative diseases and the neuroses. The diseases of the nervous system which owe their development to these initial pathological disturbances will then be eniunerated under their respective headings. ACUTE INFLAMMATORY DISEASES. Epidemic cerebrospinal meningitis. — The back- ache in this affection very often ushers in the dis- ease. It is indeed a major complaint in a great number of cases as long as consciousness is present. Its severity is evident by the plasterlike rigidity which envelops the entire spinal musculature. This rigidity lasts throughout the disease and all spinal mobility is practically abolished, the slightest move- ment of the spine, either spontaneous or induced, increasing the spasm and pain to a marked degree. The pain has no localizing characteristics, but is diffuse, embracing the muscles in proximity to the entire vertebral column. The sufferer describes it as gnawing and boring, as if the entire hack would be broken by the very violence of the i)ain. Acute and chronic myelitis of the cord. — In the acute stage of this aff"ection, with involvement of the dura mater in the inflammatory process, pain in the back is a prominent subjective complaint. It comes on early in the disease, but it does not persist ; with the appearance of the paralytic phenomena the back pains usually subside. The localization of the pain depends on the anatomical location of the infectious process. This may occur either in the cervical, dorsal, or lumbosacral regions of the cord. In cases of ascending or dift'use myelitis, the sub- jective discomfort may involve the entire back. The pain in the.se myelitic conditions is usually described as burning. In two cases observed per- sonally the patients complained bitterly of an intense paresthesia in the back muscles which shifted from segment to segment. After the subsidence of the acute stage, and when the myelitis passes into the chronic phase of the disease, all back pains usually di.sappear. Landry's paralysis. — Backache in this affection is ajiparently not a constant symptom, if one closely analyzes the clinical description of the disease. Some authors have dwelt with particular emphasis on the severe diffuse boring and burning pains in the muscles of the back and along the vertebral column. Other authors have apparently not ob- servecl this symptom or have ignored it in the description of their cases. \'on Leube observed one case in which the pain along the vertebral column was most intense when the patient sat up. On lying down the pain disajjpeared completely. Vigorous pressure over the spinal muscles also failed to elicit any discomfort. The chaotic and varying pathology of the disease may possibly explain the inconstant presence of this subjective symptom. Acute poliomyelitis. — In the severe types of thi.s affection with dural involvement the backache is very severe and persistent and assumes the charac- teristics of the pains in cerebrospinal meningitis. They may be coincident with the on.set of the infec- tion or may precede it for a number of days. The spinal muscles are held rigidly, all movements, either volitional or induced, intensifying the distress. The pains persist throughout the acute phase of the dis- ease and subside with the onset of the paralytic phenomena. This is not constant, however, for in a considerable number of cases observed in the epidemic of 1916 the spinal rigidity and ])ain per- sisted months after the development of the ])aralysis. Evidently a subacute pachymeningitis was respon- sible for the persistence of the symptoms. The back pains, as described by mature patients, are diffuse, boring, and tearing, with a subjective sense of tremendous weight and pressure. In mikl cases of poliomyelitis there is a> a rule no complaint of backache. A vague sense of discomfort dift'u>ed over the entire back has been observed in the moderately severe cases of this disease. Herpes zoster. — Severe and persistent pains in the back will in a great majority of cases herald the advent of this affection. The pain is sharjilv localized and is in approximate relation to the in- volved posterior root and its ganglion. It is de- scribed as gnawing and burning in character. W'nh the appearance of the herpetic vesicles, the i)ain> assume a radiating character and are definitelv marked by the anatomical distribution of the inter- costal nerves. It is well to bear in mind the pos- sibility of a zoster infection in a sharply localized pain with sudden onset limited to the spinal mus- culature. A special characteristic of herpes zoster pains are their persistence long after the disappear- ance of the vesicles. They assume a definite neu- ralgic character which may affect the back or sides of the thorax or trunk with equal persistencv. HEMORRHAGE. Hemorrhage aft'ecting the spinal meninges ( hematorrhac'ii-^ ) is associated with backache of the most violent kind. The extrava.sation of blood may occur either in the epidural or subdural .--pace. .As soon as the bleeding occurs 'he irritative plienomena assert themselves almost at once. There is excru- ciating pain .sharply localized and in api)roximate relation to the site of the hemorrhage. This locali- 140 ROSEXHECK: NEUROLOGICAL BACKACHE. [New York Meo[C.\l Tourxal. zalion does not persist, however. As the blood gravitates in the dural sac the pains travel down- ward and eventually involve all of the spine below the point of bleeding. The back muscles become very rigid and pressure o^ movement increases the distress a great deal. The pains persist with vary- ing intensity for a considerable period after the hemorrhage has ceased. With the absorption of the clot they gradually diminish in severity and eventually disappear. It is well to mention here that in large hemorrhages — the socalled spinal apoplexy — the back pains may at once, assume a radiating character, due to pressure on the posterior roots. This radiation is a late symptom in the majority of cases, and appears usually with the onset of the paralytic phase of the affection. Hemorrhage into the cord substance ( hemato- myelia), if extensive, may produce backache as the result of lateral distention of the cord with conse- quent pressure on the dural covering and the pos- terior roots. The pain is of sudden onset, becomes sharply localized, and is in approximate relation to the site of the hemorrhage. This back pain, how- ever, is of a fleeting character, soon to be followed by the onset of the paralysis. In most cases of hemorrhage into 'the cord substance the initial pain is absent. It is the paralytic phenomena that at once present themselves. VASCULAR DISTURBANCES. Hyperemia of the cord as a cause of backache was a common diagnosis and in great favor with the clinicians of the past. They evidently attempted to give a pathological status to the great and ill defined mass of back pains occurring in the various neuroses and toxemias. In the light of modern pathology the diagnosis of hyperemia of the cord belongs more to the realm of fancy than to fact. As a cause of backache, therefore, it may be left out of consideration. Intermittent claudication. — A number of authors, notably Dejerine, have described this condition as affecting the spinal arteries. On this basis he has described a syndrome characterized by severe lumbo- sacral pain with transient sensory and motor disturbances affecting the lower extremities. An analysis of this affection has led him to believe that an angiospasm of the blood vessels supplying the lumbar enlargement is responsible for the symp- tomatology. In a patient with marked evidences of arteriosclerosis, I was able to confirm Dejerine's observations. The onset was quite sudden with a marked sense of weight over the lumbosacral area. This lasted for a short time and was quickly fol- lowed by paresthesia and marked weakness in both lower extremities. There were no pathological reflexes present as observed by Dejerine and others. The deep reflexes, however, were markedly increased and an exhaustible ankle clonus was easily elicited. The sensory and motor disturbance disappeared completely in twenty-four hours, but a vague sense of pressure and discomfort persisted in the lower portion of the spine for about ten days. No doubt a great number of back pains that suddenly in- capacitate the aged are probably due to the tem- porary vascular constriction of the spinal arterial supply. VASCULAR ABNORMALITIES. The rare possibility of enlargement of the spinal veins in relation to unexplained backache is to be borne in mind. Krause, Gaupp, Jumentie, Valensie, Lindeman and Elsberg (quoted by Elsberg) have described the clinical and surgical aspects of these cases. Obviously they have dwelt in the main on the broader symptomatology of the gross sensory and motor disturbances, which the enlarged veins produce. These vascular abnormalities give the clinical picture of new growths of the cord with all their attendant pressure effects. The character of the back pains, therefore, is to be interpreted from that viewpoint and merit no special description. NEW GROWTHS. In a considerable number of tumors of the cord, particularly those of the extradural or intradural type, backache may be an early subjective complaint. The character of the pains can be described as boring, burning, or a vague sense of pressure. Its localization depends on the site of the tumor mass. Thus it may be in the cervical, cervicodorsal, dorso- lumbar or lumbosacral region of the spine. The localization of the pain does not last very long, however. As the neoplastic process spreads and an invasion of the posterior root or its ganglion results, the pains become diffuse and radiating in character. Eventually they are sharply limited to the segments involved. The nature of the pains in spinal cord tumors (the dural variety) are their severity and persistence throughout the course of the disease. The onset of paralytic phenomena does not mitigate the patient's suft'erings. Relief is obtained only by death or operative interference. In the intramedullary type of tumor we hardly ever encounter the subjective symptom of back pains. It may be observed, however, as a late symptom long after the development of the paralysis. This is to be explained by the invasion of the pos- terior roots and meninges, the inevitable result of extension of the tumor mass. The characteristics of these pains have been dwelt upon under the dural types of tumors, and need no further description. NEUROSYPHILIS. Under neoplastic processes we may well include syphilitic affections of the cord and meninges. These gummatous exudates readily assume the characteristics of tumors with all their pressure effects. Thus the localized or diffuse types of meningomyelitis may be ushered into clinical being by the advent of severe back pains. These pains have certain features that merit special description. They come on insidiously and may involve the entire musculature of the back. At times the pain is sharply localized and then again may shift about and eventually become diffuse. The distress is in- creased by pressure or movement of the spine. Rigidity of the muscles is not uncommon, and in some cases is quite marked. PacJiymeningitis ccrvicalis hypcrtropJiica. — In this affection we are also, dealing with a neoplastic ]>rocess which exerts marked pressure effects on the dural covering of the cord. As a result pain in the cervical region is a very early symptom. The pain is sharply localized and is characterized by its January 22, 1921.] ROSENHECK: X EURO LOG I CAE BACKACHE. 141 severity and persistence. It may be described as boring or pressing. Two patients under my care, who were carefully interrogated on this point, de- scribed the pain as a combination of pressure and paresthesia. The muscles in the cervical area may be quite rigid and sensitive to pressure. The local- ization of the pain lasts a variable period and is followed by the usual radiating character of pain, indicating involvement of the posterior roots. It seems opportune at this point to emphasize the fact that the pain in neoplastic processes of the cord and meninges is not at all times limited to the back. With the increase in growth of the tumor mass and inevitable invasion of the ganglia and posterior roots, the pains assume a definite radiating char- acter. It is quite obvious that this radiating pain may be the very first subjective complaint whenever pathological processes invade primarily tlie posterior roots. DEGENERATIVE DISEASES. Tabes dorsalis may initiate its chnical appearance with a persistent pain in the back. This is not per- manent nor characteristic. As we are dealing in this aiYection with a primary aadiculitis, the pains early assume a distal character. Thus the radiating or lightning pain has been recognized as an intimate associate of this disease for a great number of years. It dominates the clinical picture from its inception and definitely stamps the affection. Paralysis agitans, combined sclerosis, multiple sclerosis, and the various types of secondary tract degenerations, may at some time during their onset or course of development be the subject of pain in the musculature of the back. This discomfort is more readily explained by the fixed attitudes which the patient has to assume in getting about. The mechanical difficulties of locomotion add great bur- dens to the spinal muscles which conduce to their fatigue and discomfort. As this backache has no pathological significance, its furtlier description seems unnecessary. NEUROSES. In traumasthenia and neurasthenia, backache holds the centre of the clinical stage. Its essential fea- tures have been mentioned under the chapter on etiology. The clinical importance of this subjective complaint may be considered from the effect that it has on the patient's morale and its defiance to all accepted methods of treatment. Its economic importance claims even greater consideration, for we are all familiar with the impaired working capacity of the affected individual. In considering the backache of traumasthenia we find that it follows soon after the primary effect of the injury has passed away. The pain may be dif- fuse or localized to the lower lumbar area. In the majority of cases the lumbar type of pain is mani- fest. The distress is constant land increased by all physical effort. It is described as a sense of weight and pressure, and there are areas of extreme tender- ness to pressure. Rest has little if any influence in alleviating the pain. It may also assume a lancinat- ing character associated with moderate paresthesia. The backache of neurasthenia is a backache of adjectives, as one author has facetiously named it. It holds the patient in a relentless clutch and is usually increased by mental or physical effort. It may he localized to any portion of the spine, but as a rule involves the dorsolumbar mu.scles. Rest may mitigate the distress, but not to any appreciable degree. As heretofore stated, it is a pain particu- larly rich in adjectives, and its embellishment is limited only by the literary ability of the sutferer. The chief characteristics of this hack ])ain may be summed up as follows: Persistent and diffuse char- acter of pain ; early fatigue of back muscles after ])hysical or mental eifort ; marked points of tender- ness over muscle .segments, and evident emotional instability. DIAGNOSIS. As backache is only a symptom of a particular morbid process, it would be a manifest fatuity to speak of the diagnosis of a symptom. Obviously when a patient complains solely of back pain the most thorough inquiry and examination should be instituted, in order to discover the cause of it. A perfunctory glance and a bottle of liniment is a bit unscientific and rarely brings results. A frank neurological affection may he menacing the patient, and its diagnosis ' should be established as soon as possible, for I have observed irreparable injury to the spinal axis in cases where this humble symptom was the only complaint. It is obviously hazardous to attempt a diagnosis of the underlying condition by the peculiarities of each backache. In acute con- ditions it may be a very simple matter when other associated symptoms are apparent ; but in chronic backache, all the descriptive powers of the patient will not make the diagnosis for us. It may aid considerably in giving this symptom its proper evaluation and guide us in arriving at a definite conclusion. The practitioner must always bear in mind that it is only a symptom of an underlying disorder, wliich painstaking examination will reveal to him. TREATMENT. The treatment of backache in neurological dis- eases is obviously the treatment of the underlying condition producing the disturbance. It is not the purpose of this article to dwell at length on the methods to be pursued in each given case. They will readily suggest themselves to the intelligent practitioner as soon as he views his cases in their proper perspective. Above all. he should avoid treating backache by symptomatic means. In the main the treatment will be directed by a combination of methods which will take into consideration the primary morbid process and the evils that flow therefrom. 370 Central Park West. A Comparative Study of the Mechanism of Wound Healing. — Leo Loeb {Journal of Medical Research, January, 1920) attempts to explain on a theoretical basis the various phenomena observed during the healing of wounds. It is stated by Loeb that the reactions seen in wound healing are to be considered es.sentially as reactions of cells toward foreign bodies. 142 in I. LARD: GYNECOLOGICAI. BACKACHE. [New York Medical Journal. i GYNECOLOGICAL BACKACHE.* By E. a. Bui.l.\rd, M.D.. F.A.C.S., New York, Assistant Surgeon, Woman's Hospital A small volume might be written about backache if this symptom was studied exhaustively from every viewpoint, and a most interesting and instructive treatise it would be. I'robably the longest chapter should be written by the orthopedist, but the gyne- cologist, neurologist and internist could contribute much interesting material, and so interdependent should these be that the authors would do well to consult each other freely in the preparation of their respective monographs. Some surprising observations made in the post- operative followup clinic at the Woman's Hospital during the past few years led me to feel that an ;uialytical study of backache would be interesting. There is a justifiable scepticism of statistics. Contentions of every sort have been backed up by statistics at one time or another, but I am not trying to prove anything. I wish merely to lay before you what the records show. While there is of course a certain percentage of error in these reports. I be- lic^"e that the rather thorough methods now in operation at the W^oman's HosjMtal produce ap- proximately accurate figures of the work. Seven hundred and twenty-one cases of backache, with sufficient data for satisfactory study, were taken up in order from the records of the followup clinic since 1915 and tabulated for this analysis. GROUP I. Retroversion uncomplicated by any other gynecological abnormality 129 Cases Backache cured by operation 10,^ Cases Gilliam operation 34 Bissell operation 10 Simpson operation 14 Internal Alexander 13 Grad U Miscellaneous operations . . 13 Backache unrelieved by operation 26 Cases Simpson operation 4 Gilliam operation 4 Bissell operation A Ventral suspension 2 Round ligament ])lication. 8 Miscellaneous 4 These latter cases were anatomically successful and nothing remained to explain the failure. This, then, is a series in which the backache might reasonably have been ascribed to the displaced uterus, but end results virtually proved that twenty per cent, of these backaches were not from that cause, and were almost certainly not gynecological. GROUP II. Retroversion with adnexal inflammation . 68 Cases Backache cured by operation 59 Cases Backache imrelieved by operation 9 Cases .Xnatomically .satisfactorj- retroversion operations 'Read at the November meetin? of the New York Obstetrical '•ociety, 1919; also before the Buffalo .Xcademv of Medicine, Mav 19, 1920. with salpingectomy were performed, and no tender- ness or induration remained to account for the con- tinuation of the pain. Here we found elimination of the pressure of an adherent uterus or a tuboovarian mass, or relieving the drag of adhesions seemed to cure eighty-seven ])er cent, of the backaches, leaving thirteen per cent, jjrobably not pelvic, but not diagnosed. GROUP III. Adnexal inflammation only 19 Cases The results here seem to justify the opinion that salpingitis with adhesions produces backache, for all but two of this group were cured by ablation of inflamed tubes — and sometimes the ovaries — and the release of adhesions. About ninety per cent, were cured. GROUP IV. Lterine prolapse (of various degrees).. 84 Cases Backache cured by operation 75 Cases Various ligament operations for first de- gree prolapse 23 \\'atkins operation 20 Mayo operation 14 Bissell trisection uterus 3 Abdominal hysterectomy 3 A aginal hysterectomy with Bissell cysto- cele operation 3 Miscellaneous operations 9 Backache unrelieved by operation 9 Cases Goffe operation 2 Baldwin operation 1 Watkins operation 1 Bissell trisection uterus. . . 1 !Mayo operation 1 \'aginal plastic operations with round ligament ojjeration 3 Operation was anatomically satisfactory and no pelvic lesions found to explain continued pain. In tliis important series we found eighty-nine per cent, of the cases relieved by operation, the back- aches probably having been due to the drag on pelvic supports and therefore cured by successful ana- tomical repairs. GROUP v. Plastic oi>erati"n-> ou'v 4^^ Ca-^es Uncomplicated rectocele 9 Cases Cures 5 Failures in spite of success- ful plastic operation. ... 4 Cystocele and rectocele ( without pro- lapse ) 12 Cases Backache cured 6 Backache unrelieved de- spite satisfactory anatom- ical repairs 6 Repairs of cervix and perineum 17 Cases Backache cured 1 Backache unrelieved though the plastic operations were well done 2 Cervix operations 8 Cases These operations were j^erformed for cystic, eroded, lacerated, hypertrophied cen'ix or chronic January 22, 1921.] RULLARD: GYNECOLOGICAL HACKAi llli. 14.^ endocervicitis, and the l)ackachc was cured in every case. This group of plastic cases is too small from which to draw conclusions, but I present the figures. GROUP VI. Uncomplicated retroversion with lacera- tions of perineum or cervix ( iiack- ache cured in every case) 23 Cases Gilliam operation and perineorrhaphy 12 Round ligament operation of one or another type with repair of cervix and pelvic floor 11 GROUP VII. Uncomplicated ovarian cyst 7 Cases Backache cured by opera- tion 5 Backache unrelieved hy operation 2 GROUP VIII. Fibromyomata uteri ScS Cases Without adnexal inflammation, adhe- sions, or other complication. Backache cured by hyster- ectomy 33 Backache unrelieved by hysterectomy 5 GROUP IX. Complex conditions ^07 Cases This title is used for lack of a better one. The cases all presented a combination of lesions. The classification is most unscientific, but in every case there were two or more conditions present, each of which was capable of producing a backache. Ob- viously, conclusions drawn from the study of such a series would be of doubtful value. An example of the type of patient put into this class would be such as this : A repair of cervix, cystocele, and pelvic floor, combined with a retroversion operation and adnexal work. To detemiine the cause or cure of such a woman's backache would be a hard prob- lem. Usually, that is, in eighty-five per cent, of these patients, the backache was gynecological, for the operative procedures were successful in its relief. Backache cured by operations. . .260 Cases Backache unrelieved by opera- tions 47 Cases Though you have been deluged by figures and percentages, one fact has surely been apparent all through this analysis, namely, that there were a number of cases in every group in which ojierative results were anatomically excellent, and no gyneco- logical abnormality remained to account for the un- relieved backache. To summarize : Twenty per cent, of the uncomplicated retro- version cases. Fourteen per cent, of the uncomplicated fibroids. Thirteen per cent, of the retroversions with ad- nexal inflammation. Ten per cent, of the adnexal inflammations. Ten per cent, of the prolapse cases. Fifteen per cent, of the large complex group. Obviously, at least fifteen per cent, of the cases of backache that we see in tlie Woman's Hospital are not gynecological. Since the early days of my work in outpatient gynecological clinics 1 had been impressed by the frequency of the symptom backache. Stimulated by the writings of l>radford and Lovett, Dickinson and Truslow, and others, 1 became more interested in this symptom and acquired the habit of referring many ]>atients with obscure backache to clinics in internal medicine, orthopedics and neurology for further investigation. Most often it was the ortho- pedist who cleared up the diagnosis and the fre- quency of such conditions as sacroiliac joint trouble, lumbar myositis, arthritis of lumbar spine, disturbed muscle balance, flat feet, spinal curvatures, faulty attitude, etc., was interesting and instructive. Dr. George Gray Ward, jr., chief surgeon of the Woman's Hospital, holds a similar opinion concern- ing the frequency with which gynecological and orthopedic causes coexist in the i)roduction of back- ache in females, and has established an ortho])edic gynecological clinic at that hospital largely for diagnosis. As I meditated on my series of cases it occurred to me that it might also be of considerable interest to gather u]) and classify those cases in whicli the more common gynecological causes of backache were present, but which I had discarded as I went along because none of the patients had ever had a back- ache. SERIES I. Adherent retroversion with inflamed adnexa 47 Cases SERIES II. Uncomplicated mobile retroversion 20 Case- SERIES III. Prolapse of various degrees 20 Case-^ SERIES IV. Procidentia 9 Cases SERIES V. Complex cases (with .several gynecological conditions in each case capable of producing backache ) 29 Case- Total 125 Case. CONCLUSIONS. 1. In a series of 721 cases of backache studied at the Woman's Hospital, eighty-five per cent, were cured by an appropriate operation. 2. About fifteen per cent, of this series presenting one or more common gynecological causes of back- ache were not relieved of the backache by anatomic- ally satisfactory operations. 3. Probably much more than fifteen per cent, of the backache in females is not gynecological. 4. My series suggests that fifteen or twenty per cent, of all women with retroversion, prolapse, pel- vic inflammations, ob.stetrical lacerations, or pelvic tumors, do not have backache. 5. Closer cooperation with the orthopedist, the internist and the neurologist should enable us gyne- cologists better to diagno-^e and treat backache in women. 47 E.vsT Fifty-seventh Street. 144 SOLIS-COHEN: LATEST PULMOXARY TUBERCULOSIS. [New Medic.vl York Journal. LATENT PULMONARY TUBERCULOSIS IN ITS VARIOUS DISGUISES. By Myer Solis-Cohen, A.B., M.D., Philadelphia. Pulmonary tuberculosis one naturally associates with symptoms referable to the lungs. Its occur- rence without cough and expectoration is not gen- erally recognized, nor indeed much referred to in lectures, medical articles, and textbooks. When these symptoms are lacking, therefore, the pul- monary condition frequently fails of diagnosis, especially if the physician does not make a practice of examining the lungs of all his patients, no matter what their complaints. I use the term latent pulmonary tuberculosis for those cases of tuberculosis of the lungs in which there is no cough. The symptoms the patients com- plain of are many and varied, but may be divided roughly into several groups, namely, nervous, auto- nomic, gastrointestinal, asthenic, rheumatic, derma- tological, cardiac, menstrual, and general. As might be expected, patients without cough seldom find their way into sanatoria, and thus are not so well known to the sanatorium physicians, from whom much of our knowledge in regard to tuberculosis naturally comes. I have never seen a latent case in either of the sanatoria with which I have been connected, the cases I am reporting being found in the course of my private practice. In fact, it is the general practitioner, the neurologist, the gastro- enterologist, the internist who sees these cases, and in many instances unfortunately fails to detect their tuberculous nature. The tuberculosis specialist, as a rule, meets with them only when he examines the presumably healthy members of the family of a tuberculous patient ; for seldom does a patient with- out cough visit the office or dispensary of one who treats only tuberculosis. That many other symp- toms in addition to cough, expectoration, hemo- ptysis, fever, and night sweats may occur in patients suffering from pulmonary tuberculosis is a matter of common knowledge, although sufficient attention or emphasis has not been given to them. But that these phenomena may be present in pulmonary tuberculosis while symptoms referable to the lungs are absent, is less generally known. Consequently tlie admonition to physicians to examine carefully the chest of all patients with cough, and the warn- ing to the laity about neglecting the chronic cough, are of no avail in discovering these latent cases. Nor will but a fraction of such unrecognized cases be found among the public health morbidity records, which consequently may often be misleading. In the absence, therefore, of much definite data in regard to this condition, which I believe to be f|uite widespread, I have attempted an analysis of seventy-five of my patients exhibiting pulmonary consolidation without suffering from cough. It must be remembered that the symptoms noted in cacli case are merely those of which the patient complained. There has been no attempt at a thorough investigation of each patient as to the j)rcs('nce or absence of the various symptoms, with llic exception of autonomic phenomena in a number of the cases. Had they been systematically in- quired for, no doubt various nervous, gastric, general, or other symptoms might have been elicited from patients who did not think to mention them. The number of patients reported as complaining of a certain symptom, therefore, merely serves as an index to the frequency that symptom is complained of, but must not be computed in an accurate or even approximate percentage. For convenience I have grouped the symptoms under seven heads : Nervous symptoms, autonomic phenomena, gastrointestinal disturbances, pains, menstrual and other pelvic disorders, skin eruptions, and general or systemic symptoms, the last includ- ing asthenic, cardiac, and other symptoms. Sex, age, and social condition. — Of the seventy- five patients included in this analysis twenty-four are males and fifty-one females. Four were ten years of age or younger, thirteen between eleven and twenty, twenty-nine between the ages of twenty- one and thirty, sixteen between thirty-one and fifty, seven between forty-one and fifty, and one in each of the next two decades. The age was not recorded in the rest. Forty-two were single. Five were widowed or divorced, two of whom had remarried and the second consort was living. The rest were married, the consort being ahve. Classification. — One was in the far advanced stage (according to the classification of the National Tuberculosis Association) ; the rest were socalled incipient or first stage cases. Three were in Tur- ban's class two, one in his class three, and the rest in his class one. Family history. — Thirty-two gave a family his- tory of tuberculosis, seven a history of a long stand- ing cough in a parent, six a history of tuberculosis in the consort, and nine a history of tuberculosis in the children. Twenty-six gave a family history of autonomic disturbance, eleven a neurotic family his- tory, seven a family history of enlarged thyroid gland, and seven a history of alcoholism in a parent. Factors associated with the onset of sxinptoiiis. — The chief symptoms from which the patients com- plained dated from an operation in five, from men- tal strain or grief in four, from coming to a city in four, from an illness in four, from an accident in two, from marriage in one, and from a confine- ment in two. The)' became worse after mental worries in seven, after an accident in three, after marriage in two. and after pregnancy in two. Distribution of symptom groups. — Sixt3'-three of the patients complained of nervous symptoms, fifty-two of pains, fifty-one of autonomic phe- nomena, thirty-five of gastrointestinal disturbances, twenty-eight of menstrual disorders, sixteen of skin eruptions, and sixty-seven of asthenic, cardiac, gen- eral, and other symptoms. Three of the patients complained of symptoms in all of the seven groups, nine of symptoms in six of the groups, twenty of symptoms in five, seventeen of symptoms in four, fourteen of symptoms in three, seven of symptoms in two, and three of symptoms in but one of the groups. Each symptom under the group headings is followed by the number of patients in whom it wa's noted. A'crz'ous symptoms. — The chief nervous symp- toms complained of were: Nervousness, fifty-six; Januarv 22, 1921.] SO LI S -C O HEN : LATENT PULMONARY TUBERCULOSIS. 145 depression, twenty- four ; insomnia, twenty -one ; irritability, twenty-tliree ; excitability, sixteen ; rest- lessness, twelve ; being fidgetty, eight ; tremors, nine ; hysteria, six ; twitching, six ; nervous prostration, seven ; disagreeableness, five ; mental tire, five ; hysteria, five, and nausea or vomiting accompany- ing headache, six. Less frequent were the following: Feeling of impending danger, three; sexual hyperesthesia, three; masturbation, three; phobia, three; bad be- havior, three, and mental confusion, three. Occa- sional symptoms were, gaping, two; nightmare, two; aphonia (hysterical), two; globus hystericus, two ; diarrhea when nervous, two ; epilepsy, two ; self consciousness, two ; and dreams, loss of memory, stupidity, chorea, abdominal pain during electrical storm, somnambuHsm, stiffness in legs, "picking" in arms, itching of legs, melancholia, sighing, and \ omiting when excited, each one. Pains. — Of the pains complained of the most frequent were : Headache, thirty-one ; backache, nineteen ; pain in the legs, fifteen ; in the precordium, twelve; in the chest, twelve; in the back of the neck, eleven ; in the abdomen, eleven ; in the sacro- iliac joint, eleven ; in the shoulder blade, five ; in the supraorbital region, five ; in the arm or arms, five ; and in the shoulder, five. Less frequently they were in the knee, four ; sternum, four ; thigh, three ; breast, three ; hand, three ; between the shoulders, three ; in the ankles, three ; and in the finger, three. Occasionally they were in the side of the face, two : elbow or elbows, two ; ear, two ; hip, two ; eyes, two ; below the clavicle, one ; in the scalp, one ; lips, one ; back of the chest, one ; jaw, one ; pelvic region, one : epigastrium, one ; feet, one ; thyroid gland, one ; and all over, one. Several patients complained of back- ache associated with nervousness, one of pain in the finger tips and nails when nervous. In several (four) the pain was worse on excitement and worry and in one case it was brought on by them. Three patients complained of pain on urination, one of pain in the end of the penis, and one of pain on coitus. Six patients complained of what they called neuralgia, one of rheumatism, and one of stiffness in the neck. A:itcr.c:^.'.ic f'I'.cv.cir.cr'.::. — The autonomic phe- nomena were studied more thoroughly than any other group of symptoms, because for the past fifteen years or more I have been impressed with the frequency of the phenomena of autonomic ataxia in tuberculous subjects. Those most fre- quently met with were dermographia, forty-four ; pallor, forty-two ; tricolored finger nails, thirt}-- seven ; sweating, exclusive of night sw-eats, thirty ; flushing, thirty ; showing of sclera above or below the cornea on opening the eyes widely, twenty-four ; subjective sensation of cold, twenty-three ; migraine, twenty-two ; raising of the eyebrows on opening the eyes widely, eighteen ; bleedings, exclusive of hemoptysis, eighteen ; urticaria, seventeen ; the leav- ing of a black line when a silver probe is drawn across the face, fifteen ; showing of sclera normally above or below the cornea, seventeen ; feeling worse in hot weather and better in cold weather, fourteen ; nosebleed, eleven ; angioneurotic edema, nine ; show- ing of sclera above or below the cornea on raising the eyebrows, nine ; tendency to bleed easily, eight ; numbness, eight ; general burning, seven ; subjective sensation of heat, seven ; enervated by heat, six ; worse in the winter — inability to stand the winter well or to stand cold water, six; rigor, six; pros- trated by heat, six ; low blood pressure, five, and hoarseness without a "cold," five. Less frequently were noted tingling, four ; uni- lateral burning, four; vomiting accompanying pain, four ; nausea accompanying pain, three ; asthma, three ; hay fever, three ; sweating with weakness, three ; food anaphylaxis, three ; and, occasionally, inability to stand constriction about the neck, two; showing of sclera above or below the cornea on fixing the eyes, three ; weak voice, two ; closing of the throat, one ; dryness of the lips, one ; throbbing of the head, one; sunstroke, one; hot flashes, one; eyes hot, one ; feeling of cold water running over the body, one ; nausea with weakness, one ; nausea with insomnia, one ; tight feeling in the head, one ; desire for sweet things preceding migraine, one; great desire for food preceding migraine, one ; diarrhea when tired, one ; bearing extremes of weather badly, one ; swelling of fingers when excited or washing clothes, one; cyanosis, one; and idio- syncrasy to quinine, one. The thyroid gland could not be felt in twelve cases, was merely palpable in fifteen, and was slightly enlarged in eight, moderately enlarged in fourteen, and markedly enlarged in four. Gastrointestinal symptoms. — The chief gastro- intestinal symptoms complained of were nausea, nineteen; eructation, sixteen; vomiting, eleven; epigastric pressure, smothering, lump, weight or heaviness, eleven ; epigastric pain, ten, occurring im- mediately after eating in one case, and one hour after, two hours after, and with no relation to eating in three cases each ; pyrosis, nine ; abdominal pain, nine ; sour taste, eight ; appendicitis-, six ; so- called nervous dyspepsia or nervous indigestion, six ; heartburn, six; and distention, five, Less fre- quently were noted bitter taste, three ; epigastric tenderness, three ; pylorospasm, three ; gastrointes- tinal attacks, three ; hemorrhoids, three ; blood passed by bowel, three ; diarrhea, three ; and, occasionally, salivation, two ; cardiospasm, two ; rectal prolapse, two ; gastric distress, one ; hyperacidity, one ; ab- dominal pain after eating, one ; abdominal pain when the stomach is empty, one ; "boiling" of the stomach, one ; disturbance from gas, one, and mucous colitis, one. Pelvic symptoms. — The most common of the menstrual and pelvic disorders were dysmenorrhea, sixteen ; exacerbation of other symptoms during the menstrual period, ten ; irregular menstruation, ten, and menorrhagia, nine. Less common were metror- rhagia, three ; increase of headache at the menstrual period, three ; and, occasionally, pain or heaviness in the breast during menstruation, two ; frequent menstruation, two ; exacerbation of symptoms dur- ing pregnancy, one ; during confinement, one, and (luring lactation, one; subjective sensation of cold immediately preceding menstruation, one; backache at the menstrual period, one ; hemoptysis during pregnancy, one, and at the menstrual period, one; nosebleed at the menstrual period, one ; scanty men- 146 SOIJS-COHEX: LATENT PULMONARY TUBERCULOSIS. [New York -Medical Journal. stniation, one, and enlargement at the menstrual period of a btirsa on the wrist, one. General symptoms. — Of the symptoms classed as general those most frequently complained of were weakness, forty-three ; tendency to tire easily, thirty- eight ; being always tired, twenty-eight ; malaise, twenty-five ; dyspnea on exertion, twenty-six ; ver- tigo, twenty-six ; palpitation on exertion, twenty ; anorexia, nineteen ; loss of weight, nineteen ; failure to gain weight prior to treatment, eighteen ; failure to gain weight after treatment, sixteen ; dyspnea, sixteen ; listlessness, languor, lack of ambition, fif- teen ; constipation, fifteen; exhaustion, fourteen; palpitation, fourteen ; sore throat or dysphagia, eleven ; hemoptysis, nine ; lessened appetite, nine ; furunculosis, eight ; fainting, seven ; f reqtient urina- tion, seven, and increased pulse after exercise, five. Less frequent were drowsiness, four; acne, four; sacroiliac strain, four ; xiphosternal crunching sound, four ; circles under the eyes, three ; carbuncles, three, and tenesmus or burning on urination, three. Occasionally were noted eczema, two ; falling of the hair, two ; inclination of the head to one side, two; maculopapular eruption, two; emaciation, two; precordial fluttering, one; miliaria, one; erysipelas, one; inability to void urine, one; sexual weakness, one ; emissions, one ; nephroptosis, one ; leucorrhea when exhausted, one ; abscesses, one, and a feeling of a weight on the chest, one. The pulse and temperature were not recorded in every case. The pulse was 70 or below in one case, between 71 and 80 in eighteen cases, between 81 and 90 in eighteen cases, between 91 and 100 in seventeen cases, between 101 and 110 in eleven cases, between 111 and 120 in three cases, and between 121 and 130 in one case. There was no fever in nineteen cases, a fever of 99.5° or less in fifteen cases, between 99.6° and 100° in four cases, and between 101° and 102° in one case. The hemoglobin was between ninety-one and one hundred per cent, in one case, between eighty-one and ninety in three cases, between seventy-one and eighty in two cases, between sixty-one and seventy in three cases, between fifty-one and sixty in four cases, and between forty-one and fifty in two cases. Effect of treatment. — As a rule the symptoms described do not subside on symptomatic or ordi- nary treatment. Salicylates, aspirin, novaspirin. atophan. and oil of gaultheria frequently have no efifect on the pains. Bromides control but a small proportion of the nervous symptoms, and valerian fails in about half the cases. Stomachics, as a rule, ar^ of little benefit for the gastrointestinal symp- toms. Hexamethylenamine does not relieve the urinary symptoms. Iron, arsenic, the glycerophos- phates, calcium, digitalis, strychnine, sparteine, pic- rotoxine. atropine, and belladonna are of apparent benefit in about half the cases where they seem to be indicated. Tuberculin is seldom of value. Iodine, given by me usually as iodoform, seems to be helpful in a little f)ver half the cases where it has been used. Preparations of the endocrine glands proved disap- pointing. Thyroid gland was beneficial in five out of seventeen cases, tliymus gland in one out of five cases, pituitary gland in one out of four cases, and parathyroid gland and corpus luteum in none. Proper hygiene, fresh air, good food, sufficient rest, proper exercise, hydrotherapy, and Bier's hyperemia of the lungs and bone marrow are always indicated, but alone seldom suffice to produce a cure. Some few cases seem to retain their symp- toms in spite of every method of treatment. C3n the whole the therapeutic agents that seemed to be of most benefit were iodoform (C. P.), in doses of one eighth grain, increased gradually to a grain ; iron, arsenic, strychnine, picrotoxine, digitalis, valerian, and calcium in the form of the glycero- phosphate or the lactophosphate. Discussion. — My desire is merely to record the various symptoms and phenomena that may be ob- served in latent pulmonary tuberculosis rather than to explain them. Many, doubtless, have no connec- tion with the tuberculous process. It is possible that some may be produced as a direct result of the body's fight against the tubercle bacillus and its toxins. This is probably true of many of the symptoms that occur so frequently. I entertain the same view in regard to these as I expressed several years ago when disctissing the signs and symptoms of autonomic disturbance occurring in all forms of pulmonary tuberculosis — latent, arrested, improv- ing, .stationary, and advancing: "Aly feeling is that they are due to an excess in the system of one or more of the internal secretions, due to the stimula- tion of the thyroid gland and other endocrine glands by the tuberculous poison, and are evidences of a defense reaction. In latent . . . cases it is possible that the endocrine glands, which were stimulated to hypersecretion (and possibly hypertrophy) by the tuberculous toxin, still continue to secrete in excess of the normal after the disease has been checked, this excessive secretion giving rise to the various phenomena . . ." ( 1 ) . This view is in direct ojiposition to that held by Sajous, who believes that ttiberculosis is preceded by a weakening of the participation of the endocrine glands in sustaining the meta- bolism of all tissue cells and also their atitodefensive activity, which renders the body vulnerable to infection. To me the existence of latent pulmonary tuberculosis stiggests lessened vulnerability — tuber- culous infection with good resistance. For, were the symptoms described in this paper indicative of vulnerability, we would be likely to have active rather than latent tuberculosis. But before any theory can be formulated, much more extended studies of the ttiberculous process will be required, including the participation of the endocrine glands in the body's reaction and the effect of their altered secretion upon organs and tissues other than the lungs. Meanwhile the observant clinician may be able to contribute some aid by directing attention to symptoms and phenomena that are usually ignored. We shall be better able to detect pulmonary tuber- ctilosis when it exists without cough and to differ- entiate it from conditions that it simulates, the more familiar we become with the variotis disguises it sometimes assumes. REFEREXCE. 1. SoLis-CoHEX, MvER : American Rd'icw of Tubercii- lo.sh. 1917, 1, 289. 2113 Chestnut Street. January 22, 1921.] MELMAX: TABES MESENTERICA. 147 TABES MESENTERICA FOLLOWING INFLUENZA* By Ralph }. Melman, M. D., Philadelphia, Lecture in Pediatrics in the Medical Department of Teniiilc Uni- versity, and Assistant Pediatrist to the Samaritan .nnd (^arretson Hospitals. We have been trained to think that tuberculosi.s as a sequel to influenza is generally pulmonary in type, and, therefore, we are likely to overlook this condition if it involves any other part of the human anatomy. Especially should we be careful if this occurs in children, as the following case will demon- strate. Case. — Boy, L. C, aged seven years. His per- sonal history showed little of importance during his infancy, except a few attacks of dififused bron- chitis, due to nasal obstruction, which had been corrected by the removal of adenoids at the age of fifteen months. At the age of three he liad had measles ; no other childhood disease. Family history. — Father and mother living, and well ; two sisters living. The older sister, aged nine, was convalescing from influenza of eight days' duration when I was called in to see this boy. Present history. — The patient had been perfectly well until January 20, 1920, when a rise of tem- perature and vomiting occurred. On examination I found the temperature 105°, and the child com- plained of severe headache and general muscular pain. Physical examination revealed a well developed boy, weighing about sixty pounds. Nothing was noticed on the neck or head, except a few pal])able cervical glands. The skin was hot and dry. The eyes were injected and there was slight photophobia, but they reacted normally to light and accommoda- tion. The teeth were in good condition, the tongue was coated and the pharynx congested : chest was well developed with equal expansion on both sides ; respiration 28. A few scattered rales were present. There was no organic heart disease; pulse 110. The abdomen was symmetrical in outline, with no rigid- ity or tenderness. Considering the symptoms, physical findings and a history of contagion, a diagnosis of influenza was made and the patient treated accordingly. This condition lasted for three days, when the boy began to improve and the temperature, headache, and muscular pain subsided and continued so for four days, when suddenly, on January 27th, the patient complained bitterly of pain in the left side, just above the costal margin, increased with respiration.. With it there was again a rise in temperature to 104°, and also slight tenderness over the splenic area, which showed slight enlargement. There was also an enlargement of the liver. Pleuropneumonia or the possibility of enteric fever was considered at this stage. We eliminated the former by the absence of any of the physical signs generally present in this condition. As for the latter, we excluded it because of the negative Widal test and the presence of a leucocytosis, 17,000, also by the absence of any gastrointestinal disturbance. On February 3rd there was no change. The *Read l);fore the Medical League, December 6, 1920. general condition of the patient was fairly good; ap])etite good. He slept well, the bowels were fairly regular, and he was generally comfortalile. The temperature ranged between 104" and 105°, being at its highest between eleven a. m. and three p. m., when it would gradually subside. The phys- ical findings at this stage revealed little of impor- tance in the chest. In the abdomen, the enlargement of the liver and sjjleen became more prominent. It was thought advisable to have the child's chest and abdomen x rayed. This was done I5y Dr. Mulford K. Fisher, and he reported as follows: "Xo abnor- malities found in chest wall. In the abdomen there was found an enlarged spleen, and markedly en- larged liver." This only confirmed physical find- ings. From a further laboratory study we obtained the following results: Red blood count. o,800,000: white blood count. 6,000; ditferential normal, W idal negative, no parasites, Wasscrmann negative, feces negative; urine examination showed a trace of albu- men, no casts, diazo negative ; spinal fluid negative ; von Pirquet markedly positive — so much so that the reaction appeared as though it were a vaccinia ; blood culture, negative. Tuberculosis was suspected, but where? Our attention was directed to the abdomen, because of a slight persistent distention, uninfluenced by treat- ment, and of the enlargement of liver and spleen. The nurse was then instructed to measure the abdominal circumference daily, with the result that in three days there was an increase of an inch and a half. On February 10th it was observed that the chikl was beginning to lose weight, liad slight night sweats, the abdomen was noticeably distended, the inguinal glands were palpable and tender. At this time Dr. H. Brooker Mills and myself could palpate some enlarged mesenteric glands. In the few days that followed the child's abdomen became extremely distended, causing him great discomfort, and he complained bitterly of this condition. Active treat- ment would only give relief for a brief jjeriod. A diagnosis of tabes mesenterica was made, and a few prominent surgeons were called in consultation. They advised watchful waiting until physical signs of fluid in abdominal cavity would develop, when surgical interference would be indicated ; meanwhile instituting the usual treatment for tuberculosis. The child's condition became alarming, in spite of forced feeding; the loss of weight was alarming, the heart becoming more feeble, the child suffering greatly, due to the tympanites. We decided u])on operation immediately, which was performed under spinal anesthesia. The surgeon's rei)ort was as follows: "Mesentery covered with enlarged glands, tuberculous in character, some on the verge of breaking down, a small amount of fluid in abdominal cavity, an enlarged spleen and markedly enlarged liver, possibly due to fatty degeneration." The child made an uneventful recovery, the tem- perature dropping to normal on the sixth day after operation and remained so. He has since regained his normal weight, and is attending school at present. In summarizing, I wish to emphasize a few points which I consider important- 148 BARNES: HETERO/'HORIA AXD STRABISMUS IN NEURASTHENIA. [New York Medical Journal. 1. Severe pleuritic pain on the eighth day of the disease, which I think was referred from abdominal cavity, possibly due to the fact that this complication commenced in that part of the peritoneum, in prox- imity of diaphragm. I have since seen a case of tabes mesenterica, where the patient was operated on for appendicitis, because pain was referred to lower abdomen, with fatal results. 2. The peculiar temperature curve, being at its highest between eleven a. m. and three p. m. 3. The importance of the von Pirquet test in con- junction with other phenomena in puzzling cases, in children. 4. The importance of early surgical intervention in this disease, and not resort to watchful waiting until the glands break down and have tuberculous meningitis as a possible complication, which was the tennination of the second case mentioned above. 5. It is interesting to note that in a proportion of cases of socalled potbelly, due to rickets, where distention persists, we may have as a complication a chronic tabes mesenterica. This is at present under investigation at the Samaritan Hospital, and we may have a preliminary report on it in the near future. 933 North Sixth Street. TRANSIENT HETEROPHORIA AND STRA- BISMUS IN NEURASTHENICS. By George Edward Barnes, B. A., M. D., Herkimer, N. Y. I wish to call the attention of the profession, particularly of ophthalmologists, to an observation which I have made a few times on this subject. It is fairly well known that neurasthenic patients often have an irregular activity of the ciliary muscles. So far as I am aware, however, i^ has not been observed that they may also have an irregular activity of the extrinsic muscles. I have found that these patients, at least in rare instances, show a con- dition which is beheved by the ophthalmologists who examine them to be an ordinary strabismus or heterophoria. If one is familiar with neurasthenics, it is not difficult to explain these transient devia- tions, for they are merely instances of the irregular manner in which some of these neurasthenic patients innervate and energize the various muscles of their bodies. These irregularities can be easily observed in their walk and in the use of their arms. Instead of sending the correct amount of nervous force into the various muscles concerned in a given act and thus producing a normal coordinated action, these patients send into certain muscles an unduly large amount of nervous force, and jerky, incoordinated actions result. Acts which are ordinarily performed automatically are made more or less consciously, the will sending out into the various muscles a badly proportioned set of impulses. Of course prisms in the spectacles of these patients having temporary muscular deviation are very objec- tionable, and operations on their muscles are more objectionable. But how is the ophthalmologist to distinguish these cases from the usual forms of muscular imbalance? I am not quite positive just how this can best be done, but here are a few good suggestions. The ophthalmologist should be familiar with neurasthenic conditions so very prevalent about him, and he should know the nature of neurasthenia (1 to 4), and not attribute such a thing to that hoax and humbug and superstition, socalled intestinal autointoxication. When the ophthalmologist finds muscular deviations in neurasthenics he should try to prove their nature. The patient should be made to feel as much at ease as possible. By exercising the various extrinsic muscles and diverting the attention for a moment the spastic condition may pass oi¥. The administration of general sedatives would tend to diminish but would not necessarily remove the deviation. It is probable that these measures, combined if necessary with repeated examination's, would clear up most of these cases. On second examination a different muscle may be producing a deviation or no deviation may appear. REFERENCES. 1. Af¥ective Activity, Emotions as the Cause of Various Neurasthenic Bodily Diseases, New York Medical Jour- nal, April 4, 1914. 2. The Rationale of Neurasthenia and of Disturbances of Arterial Tension, Boston Medical and Surgical Journal, October 18, 1917. 3. The Etiology of Disturbances of the Heart Beat, Bos- ton Medical and Surgical Journal, October 25, 1917. 4. The Explanation and Treatment of the Effort Syn- drome, Neurocirculatory Asthenia (Soldiers' Irritable Heart), Medical Record, July 26, 1919. SCARLATINA.* By Hyman I. Goldstein, M. D.. Camden, N. J. Scarlatina is the scientific name for scarlet fever and refers to any case of scarlet fever, whether mild or severe. Sydenham, in 1670, first assigned this condition as a distinct disease among the acute exanthemata. It is almost constantly present in the larger cities in North America, but outbreaks of scarlet fever in epidemic form are rare in India. Japan, Ceylon, Asia, Australia, and Africa. Etiology. — Klein's streptococcus, Edington and Jatnieson's Bacillus scarlatinae, and Mallory's pro- tozoon body were each thought to be the cause. Virulent streptococci are always associated with the special organisms of the disease itself, and are known to be the cause of many of the severe com- plications that arise in the course of this disease. Jochmann found streptococci as the most common and dangerous cause of the secondary infections of scarlatina, but is not the cause of the disease. However, while we do not know the cause of scar- latina, it has been definitely proved that the strepto- coccus is the main etiological factor in the tonsillar and pharyngeal pseudomembranous conditions of scarlatina. It has been definitely established that the Klebs-Loeffler bacillus is absent in the great majority of cases in the early scarlatinal angina. G. H. Memoine, in 117 cases of scarlatinal angina, found Streptococcus pyogenes alone in ninety-three, *Read before the Camden County, N. J., Medical Society, Feb- ruary 10, 1920. laiiuaiy 22, 1921.) GOLDSTEIN SCAKLATIXA. 149 while Klebs-Loeffler was found in addition in five, and the Bacillus coli communis in nine cases. In- clusion bodies have been found by Bernhardt, Dohle, Kretschmer, Hofer, and others. These in- clusion bodies are present in the polymorphonuclear cells of the blood in scarlatina. Klimenko's fusi- form bacillus and Schultze's Alicrococcus S are not the causes of the scarlatina. At present it may be stated that the specific germ of scarlatina has not yet been discovered. Mallory and Medlar thought scarlatina might be due to a strongly gram positive bacillus (Bacillus scarlatinae) ; however, this has not been proved. GENERAL SYMPTOMATOLOGY. The disease is commonly ushered in by sore throat, headache, vomiting, together with a very rapid pulse, sharp rise of temperature, and the ap- pearance of an erythematous rash, seen usually by the second day upon the upper thorax and neck, then spreading rapidly over the entire surface of the body. The tongue becomes reddened at the tip and margins with swollen papillae projecting, giving rise to the strawberry tongue. Tiie uvula is in- jected and the buccal mucous membrane is of a bright red tint. There is tenderness about the neck, pain over the submaxillary glands, which are often swollen. The maxillary, submaxillary, inguinal and axillary glands, especially the last two groups, are nearly always enlarged. Tonsils become red and swollen and may show whitish patches. Some cases may show early marked involvement of the pharynx and with but a poorly defined, irregular, or transient, rash, or the rash may be absent. Some cases may show a very faint rash for a few hours and slight redness of the pharynx and tongue — ^often attributed to stomach upset. These are tlie cases that may cause dissatisfaction and ill feeling between the patient's family and the attending physician, because of the question of diagnosis. The trouble is that many of our mild, atypical cases of scarlatina re- semble other minor ailments. It is, therefore, advisable to withhold, in all doubtful cases, the expression of a positive opinion for twenty-four to forty-eight hours, or at least until positive evidences of disease have appeared. The prodromal symptoms are of short duration, usually a few hours, and may be entirely overlooked. The first thing noticed may be an erythematous blush appearing first over the upper part of the chest, cheeks and neck (a bright, fiery red blush). The period of incubation varies from three to seven or eight days. This period may be shortened or prolonged. The more severe the epidemic the shorter is the incubation period. SIGNS AND SYMPTOMS. During the first twenty- four hours the charac- teristic early symptoms are the sudden and abrupt onset, vomiting (often early and persistent), head- ache, intense congestion of the faucial mucous mem- brane, sore throat, rapid rise of temperature, and rapid increase in pulse rate, and sometimes convul- sions. These suddenly appearing symptoms and onset are suggestive of scarlatinal infection. Vomiting. — Von Leube attributes great signifi- cance to early vomiting, and considers it an initial symptom of the greatest diagnostic value, occurring more often in scarlatina in childhood than in any other disease, with the possible exception of ]incu- monia. Throat. — ^Early sore throat is almost as conblant as the eruption. There is present usually from the first a diffuse, mottled, congested appearance of the uvula, soft palate, and tonsils, and the tonsils are swollen and the crypts filled with exudate. The eruption in the throat makes it sore. Skin. — The early rash develops as a rule within the first twenty-four to thirty-six hours, and ap- pears as a widely scattered punctate blush, and differing from the sharply defined, pin head, slightly elevated rash of measles and the areas of pale .-^kin with the measles rash are absent in scarlatina. At the end of the first forty-eight hours, the real scarlatinal rash has made its appearance, first upon the upper thorax and then spreading quickly over the neck, chest, and extremities, but only slightly upon the face. The rash is a diffuse, scarlet blush made up of minute brightly red injected puncta, very slightly elevated and closely studded together, forming a uniform or finely mottled sur- face. The region about the mouth is comparatively free from rash. The rash develops more rapidly in blond, healthy, full blooded children than in darker skinned or pale children. The rash is more pronounced over areas exposed to irritation or pres- sure, such as the buttocks, back, bend of elbows, groins ; upon streaking or pressing the skin the red blush of the eruption momentarily pales. This pal- ing is not characteristic of scarlatina in any w ay. As stated previously, and now emphasized again, the places where the rash appears earliest are the upper thorax and neck, especially down over the subclavicular regions, far less commonly upon the small of the back. In a few hours the rash spreads all over and at the end of ten to twenty hours reaches the legs and entire trunk. I again empha- size the fact that upon the face true scarlatina rash, differing thus from measles and smallpox, is much less marked, and occurs only upon the cheeks and forehead, usually the lips and nose being free, giving a peculiar white ring, which is quite striking. The dorsal surfaces of the hands and feet show a marked eruption, while the plantar and palmar surfaces do not appear so injected. The rash remains at its maximum for from one to three days. The remit- tent intensity of the rash has been emphasized by Henoch. Pulse rate. — The pulse rate is markedly increased out of all proportion to the fever. From the second to the third day the rash begins to fade and the temperature comes down slowly but the pulse con- tinues quite rapid. In measles there is often an abrupt fall in temperature. Tongue. — The appearance of the tongue and throat are almost pathognomonic of the disease in some cases. The eruption makes the tongue sore at times, and results in the well known strawberry tongue, as mentioned above. The tongue loses its heavy coating after the second day and becomes deeply injected, the papillte at the tip and along the margins becoming more prominent, giving rise to the katzcnzunge. 150 GOLHSTEfN: SCARLATINA. [New York Medical Journal. Enlarged glands. — \'on Jiirgenscn emphasizes the diajjnostic value of early enlargement of the in- guinal glands in scarlatina. Schamberg also has emphasized the great frequency of enlargement of the inguinal, axillary, and maxillary glands. He found the inguinal glands enlarged in all cases, the axillary in ninety-six per cent., the maxillary in ninety-five per cent., and the posterior cervical in seventy-seven per cent, of the cases. The study of these one hundred cases by Schamberg showed that the maxillary glands commonly attained the largest size, and also most frequently underwent suppura- tion. In all of the one hundred cases studied, on the second or third day of the disease the enlarge- ment of the lymphatic glands was well marked. Polymorphonuclear Icucocytosis. — This condition is always present. In measles there is a leucopenia. Dohle, in thirty scarlatina cases, found inclusion bodies in the polymorphonuclear leucocytes. He did not find them after the sixth day of the disease. Kret.schmer, and Nicoll and Williams, also found these bodies in the blood smears in forty-five out of fifty-one cases. Isenschmid and Schemensky have found them in practically all the cases of scarlatina in the early stage. They are not found in German measles, measles, diphtheria, or whooping cough. The most characteristic inclusion bodies are those of a triangular form with a long, taillike end. They may be found in pneumonia. Rumpel-Leede sign. — Rumpel (1909), Leede, and Jampolis have reported and recommended as a sug- gestive diagnostic sign the appearance of petechije in the skin on the inner surface of the elbow joint, when the .skin is stretched until it becomes anemic, after a broad constricting band above the elbow- joint has been previously applied for ten or fifteen minutes and then loosened. A negative reaction is perhaps a greater indication that scarlatina is not present than is a positive reaction that it is present. Jampolis found it in 199 out of 200 cases. Bennecke confirmed the diagnostic significance of the Rumpel-Leede phenomenon. A venous stasis only being produced in the arm, the arteries being left alone, the hemorrhages appear at the elbow in from five to twenty minutes — punctate or larger, in some cases becoming confluent. He found them in nearly all cases. Desquamation. — The eruption is due to an in- flammation of the skin and to very minute vesicles which form in the deeper layers of the epithelium and loosen the cells. This loosened epithelium peels ofl:', and gives rise to the characteristic desquama- tion. Desquamation usually begins in from ten to twenty days after the onset of the disease. It begins around the roots of the nails, the palms, and soles, and extends over the whole body. Schumacher states that desquamation is not a positive sign of recent .scarlet fever, as scarlet fever can exist without any subsequent desquamation, and that desquamation may be the result of a number of constitutional diseases of long duration, as i)neu- monia and tuberculosis, or some local inflammatory condition of lengthy duration, as sunburn or ivy poisoning; or the internal ingestion of such drugs as arsenic ; or the external application of strong anti.septics, such as phenol or formaldehyde gas. Desquamation begins first where the rash was first seen and from where it first disappears, namely, the upper thorax and neck. Wassermann reaction and Babinski sign. — P. Teis- sier and R. Benard found a positive Wassermann reaction in eighty-four per cent, of the cases of scarlatina in the Hopital Claude- Bernard. The Babinski sign in scarlatina and diphtheria has been reported to have occurred in a rather large percent- age of cases, nineteen to twenty-five per cent, of all cases. Transient albuminuria. — Early in the course of the disease, albuminuria is seen in seventy-five to ninety per cent, of all cases, according to Eichhorst. Age. — The greatest number of cases occur be- tween the ages of one and five or six years. McCoUom, at the Boston City Hospital, reported that seventy-five per cent, of patients were between two and ten years of age. IMMUNITY. As a rule one attack protects against a sulxsequent infection. Second attacks have been reported. Others have reported even third attacks. One must not make a positive diagnosis of a second attack of scarlatina without first excluding all other possible conditions, and without a careful study of all the presenting symptoms and signs and a thorough study of the history of the case. Henoch has seen but one authentic case of a second attack of scarlatina. According to Korner, when a second attack occurs it usually follows from two to six years after the first (which first attack usually occurs before the age of ten years). Murchison has reported a third and Stiebel a fourth attack of scarlatina. The vari- ous erythemata must, of course, be excluded, such as drug erythema; measles, rubella, antitoxin ery- themas, toxic or simple erythemas, erythema scar- latiniforme, erythema scarlatini forme desquama- tivum, etc. Jacobsen, in April, 1914, reported the case of a family of four children who had scarlatina in 1908 and 1911. Over a year later the children had scarlatina again, each one of the children having a typical attack. The second attack was more seri- ous than the first in all, and one girl, eight years old, died from myocarditis. TYPES AND VARIETIES. Numerous varieties or types of scarlatina have been described, such as the following: 1. Scarlatina anginosa. 2. Scarlatina maligna (toxic). 3. Scarlatina modificata : a Scarlatina miliaris. b Scarlatina laevigata. c Scarlatina laevis. d Scarlatina sine exanthemata. e Scarlatina hemorrhagica. f Scarlatina variegata. g Scarlatina sine angina. h Scarlatina sine fehrc. A simple classification is this : 1. Well developed and .severe cases of scarlatina. 2. Mild cases, in which there is sore throat, and a slight (evanescent') rash, with subsequent desqua- mation or peeling. 3. Still milder case.s — not a sufficiently concen- J;iiiuar> 22. 1921.] GOLDSTEIN: SCARLATINA. 151 tratecl infection to cau.se a rash, hut which produces a sore throat, and iDossihly exfoliation of the tongiie (strawberry tongue). These sul)cases are of the greatest importance from a public healtli viewpoint. The eruption may at tii^ies be abortive, or not seen at all, or the rash fails to appear (scarlatina sine eruptione). It is possible that the rash appears, but is so faint and evanescent as to go unnoticed. MORTALITY. In a .study of 1,153 cases of scarlatina by L. I. Dublin, there were ninety deaths, or a mortality rate of 7.8 per cent. ^IcCoUom found an average of 8.4 per cent, mortality rate in 37,810 cases in Boston in twenty-eight years. In 32,317 cases of scarlatina during a twelve year period in Phila- delphia (1898-1910). 1,759 deaths occurred, or a mortality rate of slightly over five per cent. Dublin found eighty-two per cent, of all cases (1,153 in the series) were among children between two and ten years. The greatest disposition to the disease is found among children three to seven years of age, according to Dublin. According to Osier, ninety per cent, of all scarlatina deaths are of chil- dren under ten years. Dublin's figure was ninety- tw^o per cent. The mortality averages from five to twelve per cent., varying in different localities and in different epidemics, depending often on the sea- son of the 3'ear. SEOUELvB AND COMPLICATIONS. Otitis. — According to Carter, otitis is perhaps the commonest complication of scarlatina. According to Holt, perhaps seventy-five per cent, of the severe cases show otitis. In 4,015 cases analyzed by Caiger, 11.05 per cent, showed otitis media. Bader and Guinon found that thirty-three per cent, of all the cases of scarlatina showed mild or catarrhal otitis media and the purulent form in 4.5 per cent. Ten per cent, of acquired deafness has its origin in scarlatina. Barasch found among 1,438 cases 13.8 per cent, showed otitis. Fisher reported middle ear trouble in twenty per cent, of cases. Richard- son, of Providence, in a letter to me, states that about twelve per cent, of the cases show acute otitis media with less than one half to one per cent, developing mastoiditis. Finlayson, in 4,397 cases studied, found otitis in ten per cent. A'cpliritis. — Osier records the presence of nephritis in from ten to twenty per cent, of his cases. H. Barasch reports that 16.1 per cent, of 1,438 cases were complicated by nephritis, at the Urban Hos- pital, Berlin. Xo case, however mild, is wholly free from the danger of a subsequent severe renal inflammation. The occurrence of nephritis during the course of scarlatina is due to the circulation in the blood of the specific virus or toxin wliich acts as a direct irritant. Nephritis appears less fre- (|uently in young adults than in childhood. Scarla- tinal nephritis develops late in first or early in second week — from the tenth to the twentieth day of the disease. There may be, 1, early or initial mild nephritis; 2, septic nephritis, and, 3, postscarlatinal nephritis. Out of 1,200 cases, Richardson found, two or three years ago in a study of the records of the Provi- dence City Hospital, about one per cent, nephritis. with no deaths. However, since that time he found the incidence in nephritis was much greater in that one year than in all the cases he had previously put together. Wilson, of the Bureau of Hospitals, New York city, states in a communication to me that the frequency of complications in the order of their occurrence are endocarditis, angina, arthritis, nephritis, and mastoiditis. Complications are very much more frequent where the patients are per- mitted to get out of bed too soon after the fall of temperature. Bara.sch reports among the 1,438 cases above mentioned the following complications : Nephritis, 16.1 per cent.; otitis, 13.8 ])er cent.; rheumatism, 5.9 per cent.; sepsis, 9.1 per cent.; endocarditis, 1.3 per cent.; late involvement of glands in the neck, 33.4 ])cr cent, and 16.4 per cent, of the total were complicated by diphtheria. Heart. — The heart is very .susceptible to the scar- latinal poison, shown by the marked tachycardia and irregular, small, rapid pulse. The mural endo- cardium (myocarditis) is probably much more often affected than the valves themselves. Acute endocarditis is apparently rare. Murmurs may often be heard, probably due to tlie toxic myo- carditis. The rapid and at times irregular pulse is chiefly seen early in the attack. Later on the lieart sounds may lose the normal tone. This evidence of cardiac weakness may be due to endocarditis or myocarditis — probably the latter, becau.se it is usually the endocardium of the heart wall, rather than of the valves, that is involved. In cases of nephritis, there is seen in children acute dilatation and hypertrophy of the left ventricle. A. Stegemann, from an examination of forty- nine cases, found in toxic cases of scarlatina of short duration, the parenchymatous changes in the heart muscle slight. In the infectious cases of long duration there were acute parench3matous degenerations and necrosis. The number and size of the Nissl bodies were markedly decreased in severe toxic cases, in contrast with the infectious cases. He belieVes that in severe toxic cases of scarlatina, of short duration, the cause of the heart weakness lies in pathological clianges in the lieart ganglia. Adenitis. — Fisher reported that in six thou.sand cases fourteen per cent, had adenitis. The fre- quency of this complication varies considerably ; it often occurs in the early stage of the disease or at times in the second or third week. Scarlatinal sy]ioz'itis. — This is comparatively com- mon. Serous (simple) .synovitis is more common, and purulent arthritis may occur, but is not fre- quently seen. Synovitis occurs in about seven per cent, of the cases, is usually transient, nearly always apjiearing from the fourth to the tenth day, and in seventy-two per cent, of the cases affects the wrists, according to Marsden. Carslow in 533 cases found .synovitis in sixty. It is most frec|uent in cliildren past five years of age. Phlebitis. — This complication is very rare. Bronchopneumonia. — Bronchopneumonia, and even true croupous pneumonia, occur more fre- quently than we realize, particularly in nephritis cases. Pyemia and abscess of the lungs may occur. 152 GOLDSTEIN: SCARI.A TINA. [New York JIedical Journal. Acute psychosis. — Psychosis may occur in con- valescence. Diphtheria. — Diphtheria complications occur as a rule late in the course of the disease, and often after complete subsidence of the primary throat inflam- mation. Paralysis may occur in these cases. Henoch has never seen oculomotor or palatal ])ara]ysis following scarlatinal angina, except in those few cases complicated by a true diphtheria. Richardson states that among his cases diphtheria developed in only about one to three among two to three hundred cases of scarlatina every year. R. J. Wilson, of the New York Department of Health, states that diphtheria is an infrequent complication of scarlet fever, and since the advent of the Schick test it has been almost entirely eliminated as a complication in the wards of the hospital. It should be remembered, however, that secondary' infection by the Klebs-Loeffler bacilli may occur, most likely after the first week. This may be easily overlooked. It is therefore advisable to examine the throat at each visit, and if suspicious to take a culture smear at once. DIAGNOSIS. Difi'erential diagnosis must be made from measles, Duke's (fourth) disease; drug eruptions due to quinine, belladonna, antipyrine, opium, chloral, potassium bromide, potassiufti iodide, mercury and antitoxic sera; rubella (German measles); toxic transient erythema, sometimes seen in diphtheria; erythema scar latini forme, erythema scarlatiniforme desquamativum, and simple erythemas with or with- out tonsillitis (streptococcic). However, suffice it to say that in the large majority of cases the short incubation period (stadium incubation — two to seven days), the very short prodromal stage (stadium prodromorum of a few hours — twenty-four or less), the early vomiting, the early sore throat, the charac- teristic punctate fiery red eruption (stadium erup- tionis), the very rapid pulse — 140-165, out of all proportion to the temperature and general condition of the patient; Pastia's sign — an intense continuous linear exanthem in the skin folds at the bend of the elbow ; the Rumpel-Leede phenomenon ; the presence of inclusion bodies in the polynuclear cells of the blood prior to the sixth day, true leucocytosis (an absolute and relative increase of the polymor- phonuclears) ; the rapidly growing cultures (throat) of the Class coccus and the strawberry tongue — several or all of these symptoms will aid in making the correct diagnosis of scarlatina. In measles we have a leucopenia, Koplik spots, the peculiar rash, and the catarrhal symptoms and the marked contagiousness of the disease render valuable aid in diagnosis. Measles is liable to be mistaken for scarlatina only in special cases. In scarlatina there is tenderness about the neck, with pain on palpating the submaxillary glands, which are often swollen. In scarlatina, too, the congestive disturbance of the mucous membranes is mainly confined to the pharynx, tonsils, and larynx. There is much more photophobia and dread of light in measles than in scarlatina. In measles, too, there is a much more general catarrhal condition of the upper air passages, with coryza and the charac- teristic dry, croupy, hoarse, barking cough. The buccal mucous membrane in scarlatina as a rule is of a bright red tint and the uvula is much congested ; in measles (rubeola), there is a pale bluish tint, with a coated tongue (whitish fur) with a few scattered enlarged reddened papillae ; the rash in measles does not appear until the fourth day, while, as stated above, the prodromal stage in scarlatina does not last longer than twenty-four hours. The dark red maculje and papules of measles, with the slightly cyanotic features, certainly differ from the bright red punctate rash of scarlatina. The first lesions in measles appear on the upper part of the forehead, on the temples behind the ears, and on the sides of the neck. Later it appears about the eyes, mouth, and on the chin. In scarlatina, the rash first appears on the upper thorax and neck. Diarrhea is often seen in measles, rare in scarlatina, although it has been known to occur at times early in the disease. In rubella the rash appears first on the face and is very evanescent and is never entirely confluent, being always "measley" or "spotty" in appearance. Constitutional symptoms, otitis, severe pharyngeal involvement, and albuminuria, are almost unknown in rubella. This is a most benign short and mild infectious disease. The onset even is mild and slow and insidious, while in scarlatina it is always sud- den. In a report of 150 cases Griffith found some congestion of the upper portion of the anterior pil- lars of the fauces with some swelling of the tonsils in rubella, and Forchheimer described his small, discrete, dark red (not dusky) papules on the soft palate, remaining only about twelve to fifteen hours, and appearing simultaneously with the exanthem in rubella. Rehn also observed similar lesions on the soft palate and in the conjunctivae. Bolognini's pathognomonic sign of measles consists of a fine peritoneal crepitation or friction — as if two bottles were rubbed together, when the pulps of the fingers are applied with gentle pressure to the relaxed abdomen, while the legs are flexed. However, this sign is present in other affections and not of much diagnostic significance. In rubella, too, we have adenopathy in ninety-six to ninety-eight per cent, of all cases, the superficial or postcervical and the maxillary glands being most frequently involved. The occipital and the anterior and posterior auricular are frequently palpablj' en- larged. Finally, in rubella, the pinkish maculae and papules are very often discrete, but frequently be- come confluent in a few hours. They are first seen on the face and scalp, and next on the neck and upper chest, without any tendency to form groups, crescents or clusters (as in measles). Most impor- tant of all, the prominence of the eruption varies in different parts of the body. Thus the eruption has already begun to fade on the face before it has fully developed on the trunk : it is usually nearly gone on the face before it begins to fade on the trunk, and it is usually nearly gone on the trunk before the legs are involved. This characteristic appearance of the eruption on various parts of the body helps to distinguish this disease from scarlet fever and measles. January 22, 1921.] GOLDSTEIN SCARL.rriXA. 153 ERYTHEMA SCARLATIXIFORME DESQUAMATIVUM, ERYTHEMA SCARLATINIFORME, ERYTHEMA SCARLATINOIDE. There are several grades of this condition, mild and severe. The rash is often almost continuous over the entire surface. In some cases the rash is of a morbilHform type, in others of a scarlatinoid form, which at times is even punctiform in appear- ance at first, later becoming a uniform bright pink, fiery red, or sluggish livid red color. Usually the attadk is ushered in with mild or more severe febrile symptoms. Often the constitutional symptoms abate when the erythematous blush appears. In other cases, the general symptoms continue for several days after the eruption appears. The rash begins to subside in two, three, or four days with desquama- tion. Recurrences are frequently seen. The later attacks are usually mild. The rash is not usually quite so general as in scarlatina. The course usually runs from 10 days to three weeks. Typical straw- berry tongue and adenopathy are usually absent. The anginal symptoms are very slight or entirely absent, and the disease is noncontagious. Case I.— C. S., attorney, twenty-four years of age, male, white. Had had scarlet fever when six years old. In 1917 and 1918 he had had attacks of red rash, with itching and swelling, puffiness of head and face, a trace of albumin in the urine, and some sore throat. The attacks lasted about ten •days. With this diffuse uniform red rash there would be urticaria, large wheals appearing over various parts of the body, followed later by some desquamation. The third attack began early in December, 1919, with itching and burning, swelling of the entire face and scalp, numerous large wheals appearing all over the trunk, back of neck and thighs, with some fever and sore throat. Shortly afterward, a uniform fiery scarlatinoid (punctate) rash appeared all over the body, particularly marked o\ er the abdomen, neck, and back. The throat was considerably congested, and soreness was complained of. T\-pical strawberry tongue was absent. Throat cultures showed at first only streptococci, later staphylococci also. The rash began to fade after the fifth or sixth day. There was still some eruption over the abdomen and back on the seventh and eighth days of the attack. The urine showed a trace of albumin; specific gravity. 1,013; a few Ted blood cells ; squamous, renal epithelia ; a few pus cells ; ammonium urates ; total solids 30.3 grams to the litre; urea 1.3 per cent.; no acetone, no indi- can, no sugar, no casts. Desquamation was a prom- inent feature in the case, but it was scarcely notice- able on the hands and feet. At first, the case certainly strongly suggested scarlatina, and this, therefore, would be a fourth attack, if the patient was correct in his description of the attacks of 1917 and 1918, and if the historv- of true scarlatina when six years of age had refer- ence also to a similar attack of recurrent erythema. In my opinion this was a case of erythema scarla- tiniforme desquamativum ( ervthema scarlatinoides recidivans, or recurrent exfoliative erythema). Carter describes and reports a similar case in a young woman, aged twenty, who had four attacks. This was Dr. Corlett's patient, and shows the diffi- culty of establishing a diagnosis without reference to the history, and the importance of remembering that the appearance of a characteristic desquamation is by no means always an infallible si^n of recent scarlatina. In my case, albuminuria, with head- ache, sore throat, fever, extensive eruption, and marked desquamation occurred in three attacks in 1917; 1918, and 1919. Whether the attack in child- hood was scarlet fever or the first attack of scarla- tinoid erythema resembling the others, I do not know. The typical changes seen in the tongue from the third to the sixth day in true scarlatina, were absent in- my patient, although the edges and tip of his tongue were raw and congested. Desquama- tion in this case continued for only a few days, when it ceased. In true scarlet fever the desqua- mation usually lasts for two to six weeks. Recurrent attacks of scarlatina are very rare. Holt says he has never seen an undoubted instance of a second attack in the same patient. Kinnicutt reported two attacks within eight months in a boy of five years. Pritchard reported a case in which three attacks occurred within two years. Henoch only knew of one authentic case of a second attack of scarlatina. Statements by physicians that they have seen two and three attacks of scarlatina in the same patient should be accepted with some doubt because of possible errors in diagnosis and mistakes in the history of the cases. FACTS IMPORTANT TO REMEMBER. 1. At present there is no certain test for scarla- tina, just as there is no certain test for influenza and a few other common infectious diseases. 2. Many patients are not even sick enough to have a physician, and have only a very faint eruption, later followed, however, by desquamation. This is the best sign we have. 3. If a child has a desquamation of the skin two or three weeks after a slight attack of illness with slight fever, it is usually safe to say that the child had scarlet fever. 4. The causative organisms of scarlatina are found in the discharges of the nose and mouth, and are not found in the skin, nor in the scales (even during desquamation). The organisms may be present in the discharges from the ear and abscesses. 5. The mild cases, the unrecognized cases, those with discharge from the nose, throat and ears, and abscesses, are the carriers that cause most of the scarlatina cases. 6. Scarlatina is transmitted by contact with fresh discharges of active cases or with the discharges of carriers. The organisms produce the disease in from two to seven days after infection. Therefore, if a child has been exposed to infection and does not become ill within a week, he may safely be allowed to mingle with other children. 7. One attack of scarlatina usually confers life- long immunity. Carriers working in dairies or in milk establishments may contaminate the milk, and so help to spread the disease through infected milk. PROPHYLAXIS. 1 . Early discovery of cases is an important factor in the prevention of the spread of this disease. We 1 54 GOLDS 'FEIN : SCA RLA TINA . know that every case of scarlatina conies from a previous case. Unrecognized cases, missed cases, tvirenty-foiir hour cases, and atypical cases, are the ones that may be caught if the physicians, health ofificials. school doctors, school nurses, and school teachers will make more thorough and complete examinations. In suspected cases the patients should all be completely stripped and examined. 2. Prompt isolation. 3. Proper disposal of all discharges and excretions. 4. Protection of school children. 5. Proper treatment at home or in a contagious disease hospital. 6. Public health propaganda. 7. Proper attention to personal cleanliness, and suitable precautions taken by the attendants and those coming in contact with the case or cases includ- ing the physician. 8. Proper attention to toilet articles, dishes, milk bottles, doorknobs, and any other article that may have been contaminated with the fresh discharges of the patient. Disinfection or fumigation after recovery is un- important. Desquamation is unimportant, except, of course, the possibility that the skin may be con- taminated by the infected or organism bearing dis- charges from the nose, throat, and ears. The infec- tive material in scarlet fever is found in the dis- charges from the nose, throat, and ears, and in the urine and feces. Proper attention to these should be given, as mentioned above. It has been shown that ordinary cleanliness is sufficient to render arti- cles free from scarlatina germs, and that these germs are not longlived, and are readily killed. Children who live in a house where there exists an active scarlet fever case must not be allowed to attend school or play with other children, because they may come in contact with the sick child in the house unbeknown to anyone. However, if children who have had the disease and are immune, leave the house, they may be allowed to return to school. If nonimmune children leave the house, and after a period of observation for seven days do not pre- sent any symptoms, they may be allowed to return to school. TREATMENT. Avoid meddlesome treatment ; avoid overtreat- ment. Nose and throat. — Salt solution is the simplest and most efficient cleansing agent for the nose and throat. Liquor antisepticus alkalinus may also be used, with a nasal douche, every two or three hours. An ice bag constantly applied over the throat gives relief. Avoid strong, irritating, unpleasant, throat gargling solutions. Blood scrum. — The blood serum from patients who have recovered from scarlatina has been used with excellent results. An easy and practical way is to withdraw a few ounces, say four, five, or eight ounces, of the blood from the donor and immedi- ately inject the whole blood into the gluteal region of the patient. (Titrate solution is fir.st drawn through the luer syringe.) This blood is soon absorbed and the dangers of intravenous injection [New York >[edical Journal. and marked anaphylactic reactions are thus avoided. It is important to know that the donor is not syphilitic. Rest and fresh air. — The patient should be kept in bed, even in the mildest cases, and not covered too heavily. Plenty of fresh air and thorough ven- tilation are most important. The temperature of the room should be kept at about 65°-70°F. (23° C.) Avoid exposure to drafts. The patient should be kept in bed for a week, if possible, after the sub- sidence of the active febrile stage. In this way only can the danger of late renal complication be avoided, while daily examination of the urine is the only guide as to just what changes may be taking place. The phenolphthalein renal function test may be tried. Skin. — Throughout the course of the disease a tepid sponge bath should be given once or twice a day. These sponge baths diminish the tension of the skin and aid in skin elimination, besides being extremely grateful to the patient. For the itching, and later for the desquamation, cold cream or cacao l)utter or a mixture of lanolin, petrolatum and olive oil, with a little phenol (one or two per cent.), may be used. Menthol, one half of one per cent., may also be added for the relief of the itching. Unfortunately, there is as yet no specific treat- ment for scarlatina. Huber and Blumenthal ( 1 ) have reported the use of serum from the blood of convalescent scarlatinal patients with varied results in a series of thirteen cases. E. M. Landis (2) has reported a striking case of recovery following the use of antistreptococcic serum. A. Baginsky (3) reported a series of fortv-eight cases of scarlet fever, treated with Marmorek's anti- streptococcic serum, with a mortality of 14.6 per cent. Antistreptococcic serum and streptococcic vaccines may, theoretically at least, be of real value in all cases of scarlatina complicated bv strepto- coccic angina, ear infections, and abscesses. In these latter a mixed staphylostreptococcal serobac- terin may be tried. In all septic cases, and in cases threatened with uremia, the use, subcutaneously and even intraven- ously, of large amounts of sterile normal salt solu- tion has been advised by Forchheimer, E. P. Carter, and others. The object is to dilute the poison cir- culating and as a mechanical aid to diuresis and the elimination of toxins. It is possible that in the severe toxic cases much might be gained by such measures if adopted early. In the vast majority of cases with slight sore throat, little fever, and only mild constitutional symptoms, all the treatment necessary will be isolation, rest in bed, diet and nursing, local care 'of the nasopharynx and .skin, and the administration of an alkaline mixture as follows : Sodi citratis dr. iii Syrupi fl. dr. iv Liq. potassii citratis, ) ... T . ^ ^- ( aa q. s. 4 oz. Liq. amnion, acetatis, J M. Sig. : One fl. dr. in sweetened water every two or three hours. Fci'er. — In reference to the use of antipyretic drugs, Osier has properly stated that medicinal anti- January 22, 1921.] GOLDSTEIN SCARLAIINA. 155 pyretics are not of much service in comparison with cold water. Osier, Henoch, Moizard, Steffen, Cur- rie, Von Jiiryensen, Jacohi, Carter, and many others have recommended cool tepid sponge baths as the best means, the safest and most reliable method we liave for reducing the temjjcrature in scarlatina. Bowels. — Mild saline laxatives or small fractional doses of calomel, followed by an evacuating enema, are indicated. Stimulation. — When the pulse is weak, soft, and of low tension, .some form of digitalis may be used. As soon as the first sound .of the heart becomes weak or the heart sounds lose their normal tone and any threatening change is noted in the pulse, stimu- lation should and must be resorted to and insisted upon. Brandy or whi.skey in suitable doses may be given cautiously. Strychnine in small doses, with or without iron, may be given. Camphor, one to three grains, hypodermically, or caffeine sodium benzoate are of the greatest value in this condition. Sometimes, especially if the cardiac weakness is associated with marked restlessness, delirium and grave toxic symptoms, very small doses of mor- phine as recommended by Jacobi, seem sufficient, together with bromides and hot baths. Musk, if obtainable, can be tried in doses of one half to three grains. All my patients receive alkaline entero- clysis. Bicarbonate of soda solution is given by rectum in all cases, together with alkaline drinks by mouth. Plenty of orange juice, lemonade and water, milk, buttermilk, ice cream, orange albumin, kalak water, and Vichy, are allowed. Other complications, such as earache (otitis), lymphadenitis, severe anginal complications, arthritis, endocarditis, pericarditis, bronchitis, pneumonia, pleurisy, stomatitis, gastroenteritis, diarrhea, and nephritis — -all require attention and treatment as in ^ any other infectious disease. Jt is unnecessary to go into details in the treatment of these complica- tions in a paper of this kind. Diphtheria may be a complicating infection in scarlatina, and when it does occur, as shown by positive throat cultures of Klebs-Loeffler bacilli, dii)htheria antitoxin should be immediately injected and the heart stimulated. I do not believe that either belladonna or arsenic have any protective powers against scarlatina. Illingworth suggested that biniodide of mercury would cut short an attack and cause the rash to disappear rapidly. ^lehary believed salicin had some abortive power. Chlorate of potash should not be used in scarlatina. Very often I have found warm tub baths relieve nervousness and restlessness and reduce the temperature one or two degrees very promptly. Sponging — continued for ten minutes — with warm water (90°F.), with or without alcohol, may be substituted for the bath. Water should be applied freely and, if necessary, cooler water (70°- 80° F.) may be used. A good reaction should be obtained ; the patient must not get blue or remain cold. Moser reported excellent results from a poly- valent antistreptococcic serum. The serum may be u.sed against the septic manifestations. Its early use may be of value in protecting patients against subsequent streptococcic infections and serious com- plications be avoided. McCollom has recommended insufflations of calomel, instead of irrigations, for the nasopharynx. R. Koch reports excellent results in the treatment of scarlet fever with intravenous injection of 100 c. c. of serum taken from convalescents; that is, at about the third week of the di.sease. Among 280 cases of extremely severe scarlet fever, only one patient died, and this was a child who was moribund when first seen, dying in an hour. Con- valescent and normal serum act alike, but the for- mer is more powerful. It requires 50 c. c. for very young children and 100 c. c. for older ones; it is better to mix the serums of several convalescents. It is most efficient during the early stages of the disease. Koch regards it as an almost absolutely certain weapon during the early stages of the dis- ease if given intravenously and in sufficient doses. A. Zinglier, of New York, treated scarlatina with fresh blood from convalescent patients. He injected directly or first citrated by adding one c. c. ten per cent, sodium citrate solution to one ounce of whole blood, making the final dilution of the citrate 0.33 per cent. Four ounces can easily be injected in a young child, and eight ounces into an older child. He reported treating fourteen toxic cases in this way. The majority of the patients were very toxic and often delirious. Gabritschew.sky, in 1905, introduced the use of streptococcic (cocci from cases of scarlatina) vac- cine for preventive inoculation, and was used quite extensively in l\u^>ia. R. M. Smith concludes that Gabritschewsky's vaccines do appear to have some influence in controlling epidemics of scarlatina, and should lie tried. Russian physicians used it exten- sively. Watters tried this preventive inoculation on twenty-one nurses who had not had scarlet fever previously. Reiss and Hertz used the mixed serum from several scarlatina cases (convalescent), injected it intravenously in large doses. They believe in its preeminent efficacy, and as actually life saving, in many cases. Fifty c. c. for children and 100 c. c. for adults. Injections must be commenced before the fourth or fifth day to be promptly effectual. Normal serum seemed entirely impotent. They took the serum from convalescents between the eighteenth and twenty-fourth days, after negative Wassermann and excluding tuberculosis and septic ca.ses. Meltzer, Auer, Morgenroth, and Levy have shown that absorption from muscle is very much faster than it is from subcutaneous tissue. In fact, the rapidity of action of substances so injected approximates very closely that following an intravenous injection. Twenty-three patients treated at Willard Parker Hospital with intramuscular injections of blood. Distinct beneficial results were noted in the very severe cases by Abraham Zingher. D. Maclntyre treated septic scarlet fever cases with autogenous streptococcic vaccine in the acute stage. All the patients recovered. John A. Kolmer does not think streptococcic immunization has any value as a prophylactic measure against scarlatina, {•".pinephrine, in ten to twenty drops at a dose by mouth, was used by Paoloantonio in kidney cases of scarlatina, and in urgent cases with hematuria he gave it sulicutaneously. 156 CUMSTON: SEBORRHEA OF SCALP. [New York Medical Journal. REFERENCES AND BIliLIOGRAPIlY. 1. HuBER and Blumenthal: Berliner klin. Woch., No. 31. 1897, p. 671. I. Landis, E. M.: Journal A. M. A., April 8, 1899. 3. Baginsky, a.: Berliner klin. Woch., 1896, No. 33, p. 34. 4. Leede : Miinchen. med. IV ochcnschr., 1911, Iviii, 293 and 1673. 5. Jampolis, Mark: American Journal of Diseases of Children, June, 1912, p. 406. 6. Klimenko : Russk. Vrach., xiii. No. 8. 7. ScHULTZE : Medical Record, December 10, 1910. 8. Dohle: Centralbl. f. Bacteriolog., November 23, 1911. 9. Isenshmid and Schemensky: Miinchen. med. Woch- enschr., 1914, Ixi, 1997. 10. MacIntyre, D. : British Journal of Children's Dis- eases, London, November, No. 131, p. 470. II. Dublin, L. I.: Journal A. M. A., May 27, 1916, p. 1667-9. 12. Mallory and Medlar: Jour. Med. Research, 1916, xxxiv, 127. 13. Journal A. M. A., Editorial, p. 1206, April 15, 1916. 14. Koch : Deutsche med. Woch., Berlin, March 25, 1915, xli. No. 13, pp. 361-392. 15. ZiNGHER, A.: Nezu York State Journal of Medicine, March, 1916, xvi. No. 3, p. 185. 16. Stegemann, a.: Jahrbuch fiir Kinderhcilkunde, No- vember, 1914, Ixxx. No. 5, p. 472. 17. Barasch, H. : Deutsche med. Woch., Berlin, Jan- uary 1, 1915, xli, No. 1, p. 10. 18. Journal A. M. A., Abstract, February 13, 1915, p. 624. 19. Smith, R. M. : Boston Medical and Surgical Jour- nal, 1910, clx, 242. 20. Waiters: Journal A. M. A-., February 24, 1912, p. 546. 21. Journal A. M. A., Scarlet Fever, March 13, 1915, 908-909; March 20, 1915, 995-997; March 27, 1915, 1073-1075. 22. Zingher, A.: Journal A. M. A., September 4, 1915, 875-876. 23. Reiss and Hoertz : Mdinch. med. Woch., Munich, August 31, Ixii, No. 35. 24. Paoloantonio : Policlinico, Rome, November 30, 1913, XX, No. 48, p. 1760. 25. Jacobsen : Archives de medccine des enfants, Paris. April, 1914, xvii. No. 4, p. 255. 26. Holt : T extbook. Holt and Howland, Diseases of Childhood. 27. Anders : Practice of Medicine, Thirteenth Edition. 28. Osler: Practice of Medicine. 29. Corlett: Acute Infectious E.ranthemata, treatise. 30. Griffith, J. P. C. : Diseases of Children, 1920, two vols. 31. Nicoll, Mathias : Value of Inclusion Bodies, Re- search Laboratories, Department of Health, New York City, Archives of Pediatrics, 1913, p. 350. 32. Fischer, Louis : Treatment of Scarlatina by Neo- salvarsan, Ibid, 1913, p. 352. 33. Leopold, J. S. : Etiology of Measles, Ibid, 1913, p. 356. 34. Michael, May : Phenomenon of Scarlatina, Ibid. 1912, p. 298. 35. Miller, D. J. M. : Diagnosis of Atypical Scarlatina, Ibid. 1912, p. 289. 1425 Broadway. The Significance of Yellow Spinal Fluid. — Charles H. Nammack (American Journal of the Medical Sciences, April, 1920) says that yellow .spinal fluid occurs in a wide range of diseases of the spinal cord and meninges. The complete syndrome of Froin is comparatively rare in its occurrence. In acute and subacute conditions the presence of yellow fluid strongly suggests the probable diagnosis of tuberculous meningitis or poliomyelitis. SEBORRHEA OF THE SCALP. By Charles Greene Cumstox, M. D., Geneva, Switzerland. Since premature baldness is now recognized to be most commonly due to seborrhea of the scalp, this fact has increased the interest in this morbid pro- cess, as well as its treatment. However, only a small number of dermatologists have as yet given special attention to this subject. In what is to follow I desire to call attention to the present views held here on the pathogenesis and pathology of seborrhea of the scalp, reserving ttie question of its modern treatment for a future communication. The hygiene of the scalp is to be compared with that of the buccal cavity and teeth. The excellent results obtained in the latter prove beyond question what can be obtained by the daily systematic care of the teeth. Merz, of Bale, has said that he has observed that often the first symptoms of seborrhea of the scalp coincide with the appearance of dental caries, therefore earlier than is generally suspected. At the onset, seborrhea gives rise to little anom- alies of the sebaceous secretion, but these are easily overlooked, and since for this reason the process in its early phase is therapeutically neglected, it con- tinues to progress and to develop its destructive action. It is, above all, these early cases of sebor- rhea which require urgent treatment if baldness is to be prevented. The etiology of seborrhea is at present known, even if opinions dif¥er somewhat on certain aspects of the process. Seborrhea, which is nothing but a sebaceous discharge, is naturally related to the pro- ducing organ of sebum — the sebaceous glands which open into the hair follicles. Therefore, this morbid process is not only met with on the scalp, but on all regions of the cutaneous surface where sebaceous glands exist. The hair follicle represents an epi- thelial invagination surrounded with numerous capillary vessels whose lower part bears the papilla, that is to say, the point where the hair forms. In the development of seborrhea two states can be distinguished which are occasioned by the ana- tomical construction of the follicle. Beginning at its starting point and continuing up to the spot where the sebaceous gland opens, the wall of the follicle retains its epithehal character. It represents a simple epithelial sac, while from this point up to the papilla it has undergone the changes and differ- entiation necessary for the formation of tlie sheaths of the root. These two parts play a very different part in the process of seborrhea, but if these simple anatomical relations in the construction of the follicle be kept in mind the numerous theories of the etiology of seborrhea may be ignored. The following processes are in action during the first phase: The epithelial duct represents an excel- lent receptacle for dust and filth of all kinds. The sebum becomes thickened by the addition of these foreign bodies, while its evacuation is made more difficult, so that by its stagnation in the duct dilata- tion of the latter ensues. IMerz regards this ele- mentary process as the onset of seborrhea. In this stagnant sebum decomposition is not long in taking place and the mechanically dilated orifice — the degree of the dilatation is really extraordinary January 22, 1921.] CVMSTOX: SEBORRHEA OF SCAW. 157 —favors the development of a rich bacterial flora which finds an excellent culture medium in the altered sebum, as well as in the favorable theramic conditions offered. From the development of the bacteria, decomposition of the sebum makes rapid progress, characterized by the production of organic fatty acids. Merz is of the opinion that the bacteria constantly present are a secondary factor in the process, but many observers are of the opinion that seborrhea is a parasitic process. Lassar has tried to show the parasitic origin of the disease by mixing the hair and seborrheic squams together in vaseline and then by repeated friction of this mass on the normal skin of a rabbit which resulted in the falling of the rabbit's hair, but Michelson has shown the fall of the hair and formation of scales can be obtained by friction with rancid fats without the addition of the products of seborrhea. Sabouraud, Balzer, Bizzozero and others, who have tried to show that certain bacteria were the specific agents of seborrhea, have not been much more successful in their attempts. The supposition of a specific agent has been eliminated by Scham- berg, who has been able to demonstrate that these bacteria are the usual inhabitants of the sebaceous glands without exercising any pathogenic action. Slerz believes that these bacteria have no pathogenic signification unless they develop in abnormally large numbers. This exaggerated development is made possible on account of the favorable preparation of the soil by the process which has been referred to as taking place in the follicle. The masses of sebum, decomposed and riddled with bacteria, irritate the walls of the follicle which, on account of the rich vascular supply, readily react by an inflammatory hyperemia. The immediate effect of this inflammation is an exaggerated production of sebum which is out- wardly manifested by a more abundant discharge, in other words, seborrhea. At this phase, the sebum is principally composed of yats, masses of bacteria and horny cells. But by degrees this condition of affairs changes. The horny cells become more numerous and are the most important of all the elements, and from this time on the pathological process has entered upon the second phase. Merz defines the second phase as the propagation of the morbid process to the deeper parts of the ' follicle, from the opening of the sebaceous gland to the papilla. While the first phase may be regarded as a preparatory one, the extension of the process to the deeper structures results in serious patho- logical consequences. In the first place, a parakera- tosis and a hyperkeratosis arise in the sheaths surrounding the hair roots. The sheaths being the principal route of nutrition of the hair it can readily be understood that, following the process of para- keratosis, nutrition is made difficult and from this fact the papilla becomes compromised ; it will in- variably degenerate if the process continues for any length of time. These two states, which are pathologically differ- ent, have likewise a perfectly dissimilar therapeutic and diagnostic significance. While the primary -phase is relatively accessible to therapeutic agents and has a favorable prognosis, the second, on the contrary, is more resistant to medication and has a doubtful prognosis, especially if the affection has been present for some time. Until recently, the results of treatment for loss of hair have been far from satisfactory because the affection for a long time offers only slight svmptoms which are easily overlooked. Usually it is not the anomaly of sebaceous secretion, the abnormal drv- ness of the hair and scalp consequent upon the thickening and stagnation of the sebum in the fol- licle, or the increased fatty secretion which causes the patient to seek medical advice. The attention is attracted rather on account of the falling out of the hair which, however, may not begin until the lapse of several years. Consequently, treatment is not generally commenced until the second phase is reached, which has not a very favorable prognosis because then the organ has already become involved to an extent beyond repair. But, sometimes, it will be an acne of the face, developed simultaneously with the scalp affection that will bring the patient to the physician. The scalp and face are frequently involved at the same time, but also often one without the other. The single localization of the process on the scalp is commoner than when the face alone is affected. On the other hand, in the majority of cases of sebor- rhea of the face the same process will be found on the scalp. It begins at about puberty, sometimes quite acutely, but is more prone to assume a latent evolution. It would not be in conformity with facts to say that it never or rarely occurs before puberty, because when one is well versed in the subject, it is surprising how many cases will be found among children. Merz says that he has often seen cases of seborrhea in children from the age of five on, as well as instances wnere the process did not appear until long after puberty. He further says that he has never seen the acute forms in childhood, while they do frequently occur during and after puberty. Merz also classifies the cases as follows in respect to the age of the patient: 1, infantile seborrhea; 2, juvenile or puberty seborrhea, and 3, late forms. It is the infantile cases which have the most un- favorable prognosis if they are not treated in time and appropriately. At the age of eighteen years they may already cause falling out of the hair, both severe and lasting, and in these circumstances there is never any facial acne before the advent of puberty. These infantile forms only give rise to the most trifling symptoms during several years, but at puberty they undergo an acute aggravation. The patient will have then arrived at the second phase of the affection so that treatment then begun will no longer give good results. Often at this time the papillae are seriously affected and it is too late to stop the progress of degeneration. The symptoms of the onset of infantile seborrhea may merely take the form of very fine pellicles ; they are very adherent to the scalp and can only be removed by soap and brush ; or they may be fatty and soft, being easily detached. In spite of an energetic cleansing of the head, the pellicles always reform with a varying intensity. The formation of the pellicles may also cease spontaneously for a cer- 158 CUMSTOiX: SEBORRHEA OF SCALP. [New York Medical Journal. lain lime ami a cure is l)clievc(l lu have been attained. The use of soap and brush is a rational treatment as lar a> it goes, but in the majority of cases it is insufficient. Unquestionably, seborrhea may be cured bv simple warning, but this is rarely successful. It is certain thai a process of desciuamation simi- lar to that met with on the skin exists on the scalp without in any way being related to seborrhea, but it is impossible to distinguish macroscopically these two kinds of })ellic!es. As a rule, any mild pellicle formation in children should be regarded as a prod- uct of seborrhea. A differential diagnosis can be made microscopi- cally between a normal pellicle and one resulting from seborrhea. In the former, it is a process ot true keratini/.alion, that is to say, the cells of Malpighi's mucous body penetrate slowly through the stratum granulosum and become transformed into horny ceils by imbibition of keratohyaline and the loss of their nucleus. It is quite different in the case of a seborrheic pellicle. In this case the exten- sion of the cells of the mucous body towards the exterior takes place so rapidly that imbibition of keratohyaline and destruction of the nuclei cannot take place sufficiently, therefore the cells on the sur- face are incompletely horny and nucleated. Conse- quently, a pellicle composed of such cells is con- sequent upon seborrhea. Juvenile seborrhea — which is often accompanied by facial acne — has a better prognosis than the in- fantile form. The symptoms of the seborrhea of puberty are more marked ; besides, the sentiment of personal vanity is somewhat developed at this age and more attention is given to looks, especially to facial acne. Therefore, as these cases are treated earlier the therapeutic results will be more favor- able, but treatment must be Continued for a long time if a durable amelioration or cure is to be expected. The same may be said of the late forms which also have a better prognosis, in ail tnree forms the evolution of the affection is in a high degree chronic, even in cases with an acute onset. This formation of pellicles present in infantile seborrhea and also in a similar way in other forms, may last for years, without any visible destruction of the hair being observed. The falling out of the hair commences gradually. Some hairs will be found on the brush ; in the morning some will be found on the pillow and the increase of the loss of hair takes place so slowly that it is overlooked. Now, although these early symi)toms may seem to be insignificant for some time, they nevertheless show that the second phase has begun to injure the papillai and that treatment is absolutely urgent. This warning is frequently not observed, and it is only .some time after that, in addition to falling out, the character of the hair itself changes. It becomes dull, loses its normal turgescence and often lies flat on the head soon after it leaves the follicle, giving the impression that it is withered. Besides, it does not grow long. The ])oints are bifid and look as if cru.shed or fringed. All this signifies that there are .serious disturb- ances of the nutrition, most usually the conse(|uence of advanced morbid changes in the papilla, therefore the prognosis is bad. 1 he hair is lost and treatment must then be confined to saving the hair the least involved, because the morbid process does not develop equally all over the scalp and lying beside hairs that are beyond recovery others will be found less severely involved. In the cases where the sheaths of the root show only little parakeratosis and in which the papilla is little, if at all, involved, proper treatment may be successful, but in the more advanced cases the affection continues its progress. I'he stratum granulosum gradually disappears and the skin atrophies. The sudoriparous glands are degenerated, the sebaceous glands and muscular fasciculi disappear, while the connective tissue and elastic fibres increase. The skin having become bald is smooth and brilliant. Microsco]Mcally, hairs dead from seborrhea can- not be distinguished from those which have fallen out naturally. They have an onion shaped root ending in a point and so far as can be seen are nor- mal in their other characters. One think that is re- markable is the stability of the localization of bald- ness which occurs only on certain fixed parts of the seal]), while in other regions seborrheic alopecia never occurs. Many theories have been given to explain this fact. Elliott is of the opinion that those portions of the scalp lying upon muscles are never the seat of the process under consideration. He thinks that the play of the muscles favors the transporta- tion of the blood and lymph to the parts situated above. Schem maintains that the food supply brought for the other parts which are situated directly on the aponeurotic galea is made difficult by the tension of the occipital and frontal muscles. Merz considers that an une(|ual size of the orifice of the follicle is also a predisposing factor. One often meets, even when .sebaceous stasis is not yet marked, very large openings far from the hair, so that the latter is no longer within its sheath but in a funnel, which favors the entrance of dust, bac- teria, etc. This predisposing factor may explain why baldness is hereditary. These large orifices of the follicles are individual conditions which may be transmitted from one generation to another and therefore constitute an hereditary disposition which favors the develoiMiient of seborrhea. This is there- fore a strict indication for the resort to proper jiro- ])hylactic treatment of the scalp from childhood. 1 here append a classification given by Merz, which sums up the different phases of seborrhea of the scalp up to the time that baldness has been reached : FIRST PII.VSE. 1. Hereditary ])redisposition to seborrhea possible. 2. Penetration of dust, bacteria, etc., within the follicle. 3. Thickening of the sebum. 4. Mechan- ical dilatation of the follicular sac ; excessive bac- terial develojMiient ; decomposition of the sebum. 5. Inflammatory reaction of the walls of the hair follicle. SECCJ.XD PH.\SE. 1. l-lxtension of the inflammation to the deep jjarts of the follicle. 2. Hyperkeratosis and parakera- tosis of the sheaths of the root of the hair. 3. Dis- turbances of the nutrition of the hair. 4. Degenera- tion of the papilUe. 5. Atrophy of the skin. January 22, 1921.1 LONDON LETTER. 159 LONDON IJ^TTER. (From our owii corrcsj^ondcnt .) Women ill the Medieal I'rofessiun — /'r/ri' /;/ Ophlhalmology. LoNi)t)X, January j, jg2i. The rii.^h of candidates for admission to the medical scliools of Cireat Britain is so ^reat as to be eml)arrassing to those responsible for the manage- ment of such schools. The schools which admit women as well as men are presented with an inter- esting" problem. This new factor of the situation was largely created l)y the wartime experiment of admitting women to medicine at several of the schools, on account of the number of medical men who were called to service under the colors. The men have now returned, but find that the women have come to stay. How is the problem to be faced by those institutions which allow female medical students within their. walls? Are the women to be denied admission in the future, or are the vacancies to be divided, and, if so, in what proportion? It is said that the authorities are at the present endeavoring to evolve a definite .scheme whereby exservice men will i)robably receive preferential consideration, but the settlement as concerns the rest is a more difficult and delicate matter by far. Up to the time of the war women medical students were almo.st wholly concentrated in the Royal Free Hospital School for Women in London. After a good deal of discussion and some controversy it was resolved in 1917 to open the doors to women more generally, and the medical schools of Univer- sity College Hospital, King's College Hospital, Lon- •don Hospital, Charing Cross, Westminster, and St. Mary's hospitals, all of London, have taken in -woman students. St. George's Hospital, London, did the same purely as a war measure, and has now again closed its doors to women. The Middlesex, Bartholomew and Guy's hospitals, London, have ■consistently and firmly refused to admit women. An important reason why the problem is so hard to solve is that women are proving themselves apt pupils in the profession of medicine or surgery. The experience of the past few years has taught the lesson that not only is there a definite scope for women doctors in the fields of child welfare, public health work, and so on, but even in the practice of ■medicine generally. It has been estimated recently that if the total number of medical students in Great Britain now studying for their degrees or qualifica- tions pass successfully, that women doctors will ■represent five per cent, of the total supply. More- over, this percentage will increase rapidly, taking into consideration the fact that adoption of medi- cine by. women is a development of comparatively ■recent times. It is evident that in Great Britain, at any rate, women are now entering the medical profession in the same way and for the same reasons as men do, for the sake of earning a livelihood in a calling for which they have a liking and an aptitude, and the prejudice which existed against women doctors is ■dying out mainly because they have shown them- selves to be fitted for the work. At many of the London hospitals there are both men and women resident medical officers on duty, women patients assigned to women doctors, men patients and vio- lent cases to men doctors. Of course, at the Royal Free Hospital, London, which is the women's med- ical school, almost all the resident officers are women, and it is the usual thing for the women on duty to deal with all and any cases that come in. The task naturally often involves a considerable amount of ])hysical endurance, and much surgical and med- ical skill and judgment. It has been established beyond cavil that women are ([uite competent to undertake such duties. At the Royal Free Ho.spital there are 450 women medical students, ninety-five of whom are new this session, although the lists are not complete. Jt will be observed, then, that the (|uesti()n of wonien medical practitioners in (ireat Britain has become one of general importance. CJwing to the lack of accommodation in the British medical schools, and the large number of students to enter, the schools have a (Hfficult problem to solve in try- ing to reconcile the claims of men and women, re- spectively. However, it is certain that a feeling is growing that it is no longer possible to revert to l^rewar conditions in this direction. In America women have not progres.s'ed so far along the.se lines as in Great Britain, but this phase of the feminist movement will assuredly develop. It is impossible to speak dogmatically on the sub- ject, but it may be said that in certain branches of medicine and, perhaps, of surgery, women will find a jilace and be able to hold it. For child welfare work and for public health affairs they are pecu- liarly well adapted, and in many cases they are better fitted to attend members of their own sex than men. Indeed, there is no gainsaying the statement that women iiave demonstrated that they make capable medical ]:)ractitioners, and that there are many med- ical i^ositions which they are excellently qualified to fill. * * * Mr. W. Edmonds and Miss S. Edmonds, of Wiscombe Park, Colyton, have founded a prize in ophthalmology in memory of their brother, Nicholas Giff'ord Edmonds, who fell at Magersfontein on December 11, 1899. The prize, of the value of ilOO, will be awarded every two years for the best essay on a subject dealing with ophthalmology and involving original work. The competition is open to all British subjects holding a medical c|ualification. Subject to certain legal conditions, the management of the prize will be in the hands of a committee nominated biennially by the Medical Board of the Royal London Ophthalmic Hospital, which will select the subject of the essay and elect two exam- iners. The winner of the prize will have the option of giving a lecture on the subject at the Royal Lon- don Ophthalmic Hospital. As the subject of the essay will be announced two years before the award, ample time will be afforded for studying the litera- ture, for thorough observation, and for carrying out experiments before sitting down to the actual com- position of the essay. By their generous liberality Mr. and Miss Edmonds place the profession under a deep debt ; their wish in founding the prize is that suffering may be alleviated, and it may be confidently anticipated that this end will be attained. Editorial Notes and Comments NEW YORK MEDICAL JOURNAL INCORPORATING THE Philadelphia Medical Journal and the Medical News A Weekly Review of Medicine. Address all communications to A. R. ELLIOTT PUBLISHING COMPANY, Publishers, 66 West Broadway, New York. Subscription Price : Under Domestic Postage,6 ; Foreign
Postage, $8; Single copies, 50 cents. Remittances should be made by New York Exchange, post office or express money order, payable to A. R. Elliott Publishing Co., or \>y registered mail, as the publishers are not responsible for money sent by unregistered mail. Remittances from Foreign Coun- tries should be made with International Money Orders. Entered at the Post Office at New York and admitted for transpor- tation through the mail as second class matter. NEW YORK, SATURDAY, JANUARY 22, 1921. MAN VERSUS THE MICROBE. There appears to be a reaction on the part of the medical profes.sion against the dominance of the microbe. It has been the custom to attribute the occurrence of an epidemic of contagious disease to a certain microbe. For instance, when PfeitYer isolated a germ during the epidemic of influenza in 1889 and succeeding years, it was widely proclaimed and is given in textbooks of medicine and in medi- cal dictionaries, as the specific cause of influenza. Some hold the view that it is not the specific germ at all, while others aver that it is only one of the microorganisms concerned in the production and development of influenza. Sir William J. Collins in the Lancet for December 11, 1920, discusses this question in an illuminating manner. So far back as 1889 he said: "If it be true that in the life history of the lowest of organic things lie the momentous influences which determine plagues and pestilences, it is reasonable to believe that in organ- isms whose cycle may be less than an hour, and whose rate of propagation is incalculable, evolution must be powerfully at work eventuating in the sur- vival of those most fitted to their environment, and that in this, as in other directions, man's influence may modify natural selection and by acting in accordance with law may learn to conquer nature by submitting to her." In short, it is stated that we have been likely to regard microorganisms too much in the light of their fortuitous and unfortunate asso- ciation with diseases of man and too little in the light of their own life hi.story. In spite of what appears to be strong evidence against the absolute specificity theory of di-sease practically all textbooks of medicine state explicitly or infer that such is the case. Collins describes the orthodox credo as running somewhat as follows : "I believe that diseases, especially those which are communicable, are due each to a specific microbe, which is always derived from a preexist- ing similar organism in a previous case of disease. That such specific diseases always breed true and never arise dc novo. That immunity from attack can only ha purchased by preventive inoculation either with the specific organism alive or dead or with a serum charged with a specific antitoxin derived therefrom." , On the other hand, Collins has long contended that specificity of diseases is relatively not absolute ; that new species have evolved from time to time ; that starting from common infective agency by variation and mutual selection specific diversities of type may emerge, and that, instead of always breeding true, aberrant and typical exainples and nondescripts are commonly observed. That the condition of the blood and tissues of the body ex- posed to socalled zymotic or infective disease power- fully influences the virus of the disease to the extent of modifying, intensifying or nullifying the morbid process as soil influences the growth and results of the seed sown upon it. That the environment of the body also potentially affect its vulnerability or im- munity from disease. That if the nature of the inatcries morbi of specific infective diseases be or- ganic or microbic, such lowly organisms as have been casually associated with certain diseases are likely to be profoundly influenced by the soil upon which they are cultivated and are therefore peculiarly suscep- tible to evolutionary changes in the course of their rapid propagation and multiplication. That the pathogenetic properties of such organisms or viruses may be acquired, lost, modified, or varied during their serial cultivation in living bodies or in other culture media. Seeing that the pos.sible modes of reaction of the living body to noxious agencies or influences are limited in number and nature, similar or identical symptoms may be occasioned by dififerent patho- genetic causes ; while the same pathogenetic agencies may occasion dififerent symptoms in dififerent per- sons. That the first line of defence against invasion of the human body by infective diseases is a sanitary environment, pure air and water, good food, clean clothes and houses and that such environment pro- motes healthy living, which itself tends to raise the normal resisting powers of the body and the blood. January 22, 1921.] EDITORIAL ARTICLES. 161 So many things have to be taken into account in the evolution and development of disease, that it is difficult to believe in the hard and fast specificity of microorganisms or, at any rate, of all. \\'hen bac- teriology has not succeeded in demonstrating microbic catises in some of the most typical infective diseases, of which perhaps influenza may be cited as an example, it causes one to think and ponder. Some are veering to the belief that contagion may be in the nature of a chemical process. Undoubtedly chemicophysics is throwing a bright light upon many dark and obscure nooks and cor- ners and may in time revolutionize present day views as to the causation of infective disease. In any event, the absolute specificity theory of disease is being subjected to a good deal of criticism, some of which reads as if it were destructive and it seems as if an open mind is required by those who are delving into the secrets of disease. Such men should not be bound down by preconceived views or trammelled by favorite hypotheses but should be ready and willing, in the interests of science and humanity, to listen to any suggestions or advice which may seem likely to blaze a fresh trail, and to jttdge for themselves whether they are following a will o' the wisp or are on the high road to new dis- coveries. With regard to CoUins's statement that healthy environment, nourishing food and so on, go a long way towards rendering the body resistant to the attacks of disease, opinion is unanimous. Living under healthy conditions is a sine qua non in the practice of preventive medicine. It is indeed the keystone of health. THE PROBLEM OF THE REGISTERED XURSE. The Chautattqua School of Nursing has appealed to the courts for protection for its graduates. A Supreme Court injunction has been issued, restrain- ing the New York State Nurses' Association and the secretary of the New York State Board of Nurse Examiners from continuing to circulate any statement designed to create the belief that gradu- ates of the school will be prohibited by the laws of the State of New York from practising nursing for hire, or that such graduates, or all professional nurses, must procure a certificate from the Regents of the State of New York. The organized hospital trained nurses' associa- tions have attempte^l to monopolize the nursing field. There are not enough hospital trained nurses to supply the needs of the community, and many of the sick and disabled are unable to pay the fees of these nurses. Must they do without nurses? Graduates from the Chautauqua school have sup- plied this need for many years. During the influ- enza epidemic the scarcity of nurses was the direct cause of many fatalities. During the war the greatest aid was furnished in the military hospitISs by the auxiliary nurses. They were efficient after a few months' training, and their work saved thou- sands of Hves. Nurses graduated from the Chautauqua school fill an important need. There is no reason why the hospital nurses should fight them. There is no reason why they cannot work together in harmony, for the nurses of the school extend their services into many fields which the hospital nurses will not enter. There is plenty of work for all. There is no need to attempt a monopoly in a field of en- deavor whose purpose is the good of sick mankind. The immediate financial gain should not blind the hospital nurses to the greater gain of health to individuals and to the community. PHYSICIAN AUTHORS: DR. VIKENTY VERESAEV. One of the foremost Russian intellectuals who paved the way for the overthrow of the house of Romanoff was Vikenty Smidovitch, a physician who wrote under the pen name of \'ikenty Vere- saev. Students of the causes which led up to the Revolution of 1917 declare his stories did more than the writings of any other author to put the Russian masses into the mood for striking against czarism, and to show them how to consolidate effectively for such a step. He was the guide, phi- losopller and friend of all the revolutionary groups of Russia during the years of their preparation for the big stroke that was to come. His writings, first to last, were sheer propaganda in fiction form. Every character in his stories, every incident, had for its purpose the driving home of the hard and bitter facts of life in old Russia. He did not care whether he amused or pleased, so long as he in- flamed and instructed. S. Persky, in his Contempo- rary Russian Novelists, a prewar volume, points out that Veresaev "brought" into the world of literattire a series of characters who summed up the rising fermentation of new ideas and seemed to be the spokesman of those around whom the Russian revolutionary forces gathered, forces which up to that time had been scattered. He was I)oni," con- tinues Persky, "in the midst of the revolutionary movement and its ideas were an integral part of him. He was able to present its political opinions in such a way that their effect was tremendous. He described how the ground was being cleared for revolution and what shotild be done further to pave the way." 162 EDI TORIAL ARTICLES. [New York Medical Journal. Veresaev is scarcely known outside his native country, but within that country his fame at one time overshadowed even that of such geniuses as Chekov and Gorky. His books answered a more general need than theirs. Most likely he never will be known widely outside of Russia, for his fiction is said to be a commonplace product. As an author he never was more than a second rater, and was read more for his political opinions than for his literary talent. "Each page of him was written to throw light on social questions, considered from a well defined point of view. The secret of his success" — again it is Persky who speaks — "rests mostly in the frank, sincere manner in which he approached certain problems of vital interest to the mass of Russians." Furthermore, he expresses a deep and tender sympathy for those who suffer and always is journalistically accurate in describing what he has seen and lived through. Outside of Russia he is best known for his Memoirs of a Physician. This was his masterpiece, the cream of his literary output, despite the popu- larity in Russia of his novels and tales, and has been translated into practically all languages. These memoirs, the confessions of a doctor from the time of his earliest studies, deal with the many dishearten- ing problems which confronted physicians in Russia a quarter of a century ago. In school he learns with astonishment of the vast number of maladies that afflict mankind, and is further astonished by the fact that medicine is unable to cure many of those maladies. Later he gives his observations in hos- pitals and other practice, and comes to the general conclusion that the first step toward rectifying the evils should be a change in the social organism. "He views his profession with the eyes of a man discouraged and disheartened," says Dr. Henry Pleasants, Jr., "and shows us a conscience harassed and troubled by conditions he feels powerless to improve, leaving the reader floundering in a bog of hopeless pessimism. The book made many enemies by its frankness and angered those whose best in- terests were served in concealing the truth, but it shows how earnestly and faithfully physicians have endeavored to prove worthy of the trust imposed upon them." It is only necessary to read the Memoirs to per- ceive the moral relation between Veresaev and the heroes of his stories. The medical profession never moulded the form and context of any writer of general literature more than it did his. His medical practice gave him the background for not only some but all of his stories. "There is not a single book that might not be a confession," says one critic, "for all he writes he has experienced himself." Dis- ease and its ravages till many of his pages. Misery, despair and crime are constantly portrayed. The poverty of the villages is painted in depressing col- ors. He is perhaps the gloomiest of all Russian writers. Dr. Veresaev was the son of a Polish physician and Russian mother. He was born in Tula in 1867 and ten years later entered the local school, where he spent seven years. In 1884 he enrolled in the department of historical sciences at the University of Petrograd and got the degree of letters four years later. He then entered the University of Zhuriev ( historic Dorpat) and began his medical studies. He got his degree six years later. Two years prior to that, however, in 1892, he served as a physician's assistant in an eastern province during a cholera epidemic and also did similar service in a mining district, where he saw a peasant revolt in which several physicians were killed and others burned by the mob. He has traced these sad events in his first story. Astray, published in 1896. This story brought him immediate fame and was followed by a series of stories dealing with peasant and factory life, and outlining the various phases of the revolutionary movement between 1880 and 1890. His theory was that peasants could better their position only by getting rid of the land in order to become free proletarians. He represents the peas- ant as full of infinite egoism, without any spirit of solidarity, sacrificing everything for the love of his sorry little house and his morsel of ground, which was insufficient to nourish him. Veresaev's first medical practice was in his native city, Tula, after which he became a house surgeon in the Botkin Hospital in Petrograd, where he served seven years, until 1901, when he was expelled from Petrograd and Moscow because he had been one of the signers of a petition protesting against the brutal attitude of the police during a student demonstration. Thereafter he lived successively in Italy, Germany and Switzerland, where he practised his profession among the colony of Russian jwlitical exiles at Geneva. During the Russo-Japanese war he served as a surgeon in the Manchurian campaign and his story. III ihc War, details his experiences in the moving hospitals and the terrible sufferings of the Russian muzhiks. THI-: REASON WHY. All drug addicts can give a reason for beginning, one quite satisfactory to themselves, but they rarely furnish one for leaving off. Some, like Professor Wood, of ICdinburgh, say frankly: "I take it, sir, because I am a hedonist." Wilkie Collins took it twice a day for twenty years, saying it stimulated January 22, 1921.] EDITORIAL ARTICLES. 163 his brain and steadied his nerves. Bulwer Lytton gave the same reason. Rossetti's young wife began to take it for nervous exhaustion, and Rossetti him- self, greatly pleased with "the newly found drug, chloral," began with ten grains and finally ruined his health. One most amusing incident as to reasons happened with Coleridge and De Quincy. The first said he had to lake it for rheumatism, and wrote expostulatory letters to the latter, urging him to give it up. De Ouincy was angry, and said: "I have told the reader most truly that not any search after pleasure, but mere extremity of pain from rheumatic toothache drove me in the use of opium. Coleridge had simple rheumaUMU. Mine, which raged for ten years, was rheumatism in the face, combined with toothache. This I inherited from my father." He wrote to Coleridge, saying that simple rheumatism was not sufficient reason, but, with toothache added, any man had enough excuse, for there was no pain so acute. It was often underestimated because it had never ended fatally and often ceased suddenly. De Qtiincy was unacquainted with what the modern dentist sees in that wicked tooth which has its own way in a germ laden mouth. OPTICAL ABUSES. It is an old and approved motto in medicine that any therapeutic procedure should at least not do harm. Such a rule does not seem to "overn manv opticians, though in their practice if they do not do good they are quite likely to injure. There has come to our attention, within a few months, the following cases: A student had sufifered from head- aches since having his lenses broken and replaced. Examination showed that the lens for the right eye had been placed in front of the left eye. and that for the left in front of the right. The removal of the glasses, which were little needed, cured the head- aches. A young lady wearing glasses was, in the course of a routine examination, tested for vision, which was found to be normal. The glasses were not lenses, but of plain glass, and were fitted "because her pupils were too large." A boy of twelve with marked stral^ismus was found with similar glasses fitted at high co.st to "cure" the crossed eyes. A middleaged woman was having much trouble with her/iiew bifocals. She could not use them for near work without great discomfort. Examination revealed that the nosepiece was so wide as to throw the lenses for near work out of line of vision. A routine examination of a hundred people, in some parts of the country at least, will show many sufferers from the work of ignorant or unscrupulous glass fitters. A large number of school children are the worse for carelessness in prescribing and in fitting of glasses, and many are wearing glasses years after they have outgrown them. On this account, if for no other, there is need of more prophylaxis in schools. In .spite of the fact that medical inspec- tion tinds fewer cases of imperfect vision now than formerly, there are more defects found in children of higher than of lower grades. Many schools are still badly lighted and much night study is urged. It is evident that adult patients who wear glasses, as well as those who do not, should be examined bv the ])iiysician to whom they come lor ills referable to eyestrain, to learn whether their glasses are appropriate. Above all, tiie conscience- less fitter of glasses needs to be further scjuelclied in his work liy public measures. As a penalty for his misdemeanors he might apjiropriately be pun- ished by being made to wear misfitted glasses. The eye is too delicate and too important an instru- ment to receive other than the best of treatment. A UNIQUE CASE. It is often urged as consolation in sickness or other trouble, that there are dozens, thousands, equally or even more afflicted in a similar way. The nature of an invalid is well seen by the way this consolation is taken. He may cheerfully enter into the community of suffering if unavoidable. He may be plunged into deeper dejection because sorrow and disease are so common. He may deeply resent his claim to being a unique case disputed, because he morbidly enjoys the distinction of being more diseased than others. Watch the egocentric dilating on his case to friends: every detail is dwelt on, particularly the interest of the doctors ! A sympathetic listener will tell of one who had pre- cisely the same symptoms, even worse. The face of the first si)eaker falls. He gives an incredulous sniff and raises his eyebrows. He is annoyed and relapses into silence. It is the same with a chronic invalid if she is put in the shade bv someone in the family being taken ill. She will even cry, pre- tending her tears are those of sorrow for the invalid, whereas they are drawn by jealousy, and perhaps stay in bed in case relatives should assume she is able to help. Such ])atients are the despair n{ every doctor, because they are afraid that ctire would deprive them of the additional notice and care tliey so thoroughly enjoy, while secretly doing their best to avoid health. Pretending to grave symptoms seems to them such a nice, lazy way of gaining notoriety, because they can always get a reputation for unselfishness by saying how they would love to help if their health permitted. 164 NEWS ITEMS. [New York Medical Journal. News Items. Personal. — Dr. Alfred Gordon, of Philadelphia, has been elected a member of the Neurological So- ciety of Paris, France. Damages for Blindness Due to Wood Alcohol. —A verdict of$30,000 damages was returned in the
Circuit Court of Chicago on January 14th in favor
of the plaintiff, who was made blind by drinking
wood alcohol.

Spanish Medical Journal Changes Name. — An-
nouncement is made by the publishers that the
Reznsta dc Mcdicina y Cirugia Prdcticas, a monthly
periodical published in Madrid, has changed its
name to Archivos dc Medicina, Cirugia Espcciali-
dadcs.

Hospital for Criminal Insane in Baltimore. —

The State Lunacy Commission has submitted to the
Board of Public Works plans for the construction
of a hopsital for the criminal insane. For the build-
ing of such an institution $100,000 has been pro- vided in the public improvement loan of$1,500,000.

Historical Medicine. — The Section in Histor-
ical Medicine of the New York Academy of Medi-
cine will hold its next meeting on Monday afternoon,
January 31st. at 5 o'clock. Dr. Walter Eyre Lam-
bert will present a History of the New York Eye
and. Ear Infirmary, and an open discussion will
follow on the development of ophthalmology in New
York city.

Harvey Society Lectures. — The sixth lecture
in the series will be given Saturday evening, Jan-
uary 29th, at 8:30 o'clock, at the New York Aca-
demy of Medicine, by Sir Arthur Newsholme,
resident lecturer in charge of Public Health Ad-
ministration, School of Hygiene and Public Health,
Johns Hopkins University. His subject will be
National Changes in Health and Longevity.

Brooklyn Cardiological Society. — The second
meeting of this society will be held Monday evening,
January 31st, at 8:30 o'clock at the residence of the
president. Dr. William J. Cruikshank, 102 Fort
Greene Place, Brooklyn. The paper of the evening
will be read by Dr. Harold E. B. Pardee, of Man-
hattan, his subject being the Field of Usefulness
of Polygraph and Electrocardiograph in the Diag-
nosis of Cardiac Disease.

Reception to Dr. Keen. — On Thursday even-
ing, January 20th, a dinner followed by a reception
was given in honor of Dr. William W. Keen at the
Bellevue-Stratford Hotel, Philadelphia, by his medi-
cal colleagues. Dr. George E. de Schweinitz acted
as toastmaster and among the speakers were Dr.
Faunce. of Brown University; Dr. J. Chalmers da
Costa, Hon. David J. Hill, 'and Dr. William H.
Welch, of Johns Hopkins Lmiversity.

Reports from State Hospitals Show Increase in
Alcoholism. — Dr. Menas S. Gregory, of the
psychopathic department of Bellevue Hospital, is
credited in the public press with the statement that
a study of reports from state hospitals shows that
serious cases of alcoholism are on the increase and
that there has been a startling number of cases of
insanity resulting from what has been called whis-
key madness. Dr. (jregory is reported as saying
lliat alcoholism has increased here 100 per cent.

Bronx Hospital. — At the last meeting of the
Medical Board of the Bronx Hospital and Dispen-
sary, Dr. W. J. Robinson and Dr. Martin Rehling
were reelected president and secretary respectively.

Hospital for Joint Diseases. — At a special
meeting held on November 14, 1920, the board of
managers of the Hospital for Deformities and Joint
diseases, situated at 1919 Madison Avenue, New
York, passed a resolution recommending changing
the name of the corporation to the Hospital for
Joint Diseases. The necessary papers were filed
with the Secretary of State and the use of the new
name was authorized from December 1st.

Norwegian Lutheran Hospital Approved by
College of Surgeons.— At a "smoker" given on
January 10th to the medical staff of the Norwegian
Lutheran Deaconess's Home and Hospital, Brook-
lyn, by the board of managers, a letter was read
by Dr. John C. Bowman, of the College of Sur-
geons of North America, stating that this institution
would appear in the final list of approved hospitals.
President Larsen occupied the chair and spoke for
the institution, and addresses were delivered by Dr.
Robert E. Coughlin, Dr. Lewis S. Pilcher, and Dr.
H. Beeckman Delatour.

Cancer Committee Formed in Cincinnati. — An
organization known as the Divisional Council on
Cancer Control was launched in Cincinnati on
November 4, 1920, under the joint auspices of
the City Health Department, the Academy of Medi- ,
cine, and the Public Health Federation, for the
purpose of carrying on an intensive educational
campaign in the city of Cincinnati. Dr. J. Louis
Ransohoff is chairman of the committee and among
its members are Dr. William H. Peters, Dr. Nora
Crotty, Dr. Louis Schwab, Dr. Dudley W. Palmer,
Dr. Mark A. Brown, Dr. Robert Carothers, Dr.
Julien E. Benjamin, and Dr. Thomas P. Hart.

Association of Cardiac Clinics. — A meeting of
this association was held Wednesday evening, Jan-
uary 26th, at the New York Academy of Medicine.
Dr. May G. Wilson presented a paper on the Equi-
valent of Ordinary Exertion ; Dr. Joseph H. Barach,
of Pittsburgh, read a paper on Etiology of Cardio-
vascular Affections, and Dr. Paul D. White, of the
Massachusetts General Hospital, Boston, read a
paper on the Diagnosis of Chronic Valvular Disease.
Among those who took part in the discussion were
Dr. Lewis A. Connor, Dr. Alexander Lambert, Dr.
E. Libman, Dr. Theodore B. Barringer, Jr., and
Dr. B. S. Oppenheimer.

Medical Society of the County of New York. —
A stated meeting of this society will be held in
Hosack Hall of the New York Academy of Medi-
cine, on Monday, January 24, 1921. The program
will consist of the inaugural address of the presi-
dent. Dr. George Gray Ward, Jr., and the following-
papers : Severe Rachitic Involvements of the Tho-
rax and Certain of Their Consequences, by Dr.
Edwards A. Park and Dr. John Howland, of Johns
Hopkins Hospital, and the Treatment of Rickets.
Especially the Results Accomplished by Means of
Codliver Oil, with a lantern slide demonstration,
by Dr. John Howland. Among those who will take
part in the discussion are: Dr. Alfred F. Hess, Dr.
Oscar M. Schloss, and Dr. Walter Lester Carr.

Jiiiiuary 22, 1921.]

XEIVS ITEMS.

165

Hiccough Epidemic Alarms London. — The epi-
demic of hiccoughs is spreading through London,
and the medical profession is taking a serious view
of its progress. There are twelve cases in one hos-
pital. Some of the victims are on the verge of col-
lapse after constant hiccoughing for days. No
medical explanation of its cause has been given.

American Society for the Control of Cancer. — ■
The annual meeting of the society will be held at
the Executive Office, 25 West Forty-fifth Street,
New York, Saturda\- afternoon, January 29th, at
four o'clock. The chief business will be the elec-
tion of officers for the coming year, receiving the
report of the Budget Committee, and the election
of directors to fill vacancies of those whose terms
have expired.

No Appropriation for Long Island Hospital for
Disabled Soldiers. — The plan for a \$3,000,000 hos-
pital for disabled soldiers on the Creedmoor site in
Queens has been killed by the U. S. Senate Com-
mittee on Appropriations. The original plan was
to build the hospital for State appropriation and the
Federal Government to lease it, paying instalments
enough to cover the entire cost of the project and
then turn the hospital back to the State.

Shortage of Nurses in New York. — So great is
the dearth of nurses in several of the New York
City hospitals that the New York County Chapter
of the Red Cross has been asked to send out a gen-
eral call for volunteers to act as nurses' aids and re-
lieve the situation.

The institutions hardest hit are the Metropolitan
Hospital and the City Hospital on Blackwell's
Island and the Public Health Service Hospital at
Fox Hills, S. I., which is crowded with ex-service
men, for the most part chronic cases. The Red
Cross estimates that it can place as many as 500
women .

Damages for Prenatal Injury. — The Appellate
Division of the New York Supreme Court, by a
vote of three to two, decided recently that a child
is entitled to recover damages for a prenatal injury.
The court heard a suit in behalf of an infant, against
the owner of property, because the child's mother
had fallen through an open coal hole in the sidewalk
just before the birth of the child, which caused
permanent prenatal injuries to the infant.

Justice Merrell, writing the prevailing opinion,
ruled that the rights of human beings do not neces-
sarily originate at birth, but in many cases precede
birth in their origin.

Board of Health Demands Registration of Pat-
ent Medicines. — At a meeting of the Board of
Health of the Department of Health of the City
of New York, held on AYednesday, December 29th,
resolutions were adopted governing the registration
of patent and proprietary medicines and recom-
mending the amendment of Section 117 of the
Sanitary Code. According to these regulations,
manufacturers must file statement of quantity of
scheduled drugs and no proprietary preparations
containing harmful drugs can be registered. All
applications for a certificate of registration shall be
made upon official application blanks supplied by
the health department and signed by the applicant.
Once a month a list of registered proprietary and
patent medicines will be published by the department.

New Million Dollar Building for Peoples Hos-
pital. — The Peoples Hospital, now situated at 203
Second Avenue, has purchased as a site for a new
million dollar hospital 222 to 232 East Fifteenth
Street. The property which was purchased from
various owners consists of five four and five story
old fashioned private dwellings having a frontage
of 116 feet on the south side of Fifteenth Street.
It is hoped that twenty stories may be permitted,
though there is some fear that the zoning ordinance
may restrict the structure to fourteen. Accommo-
dations will be provided for 500 patients. Every
modern hospital develojimcnt will be included in tiie
new home. The work of demolishing the old build-
ings on the site will begin, it is planned, in six
months. Probably two years will be consumed in
completing the new building for occupancy. After
that time the present hospital will be used as a dis-
pensary.

Meetings of Local Medical Societies. — The fol-
lowing medical societies will meet in New York
during the coming week :

Tuesday, January 25th. — New York Academy of Medi-
cine (Section in Obstetrics and Gynecology) ; New York
Dermatological Society ; New York Medical Union ;
Metropolitan Medical Society of New York City; New
York Otological Society ; New York Psychoanalytical So-
ciety ; New York City Riverside Practitioners' Society
(annual) ; Therapeutic Club (annual) ; Valentine Mott
Society; Washington Heights Medical Society; Clinical
Society of the Hospital and Dispensary for Deformities
and Joint Diseases.

Wednesday, January 26th. — New York Academy of
Medicine (Section in Laryngology and Rhinology) ; New
York Society- of Internal Medicine ; New York Surgical
Society ; Brooklyn Pediatric Society.

Thursday, January 27th. — Hospital Graduates' Club of
New York (annual) ; New York Physicians' Association ;
Ex-Intern Society of the Methodist Episcopal Hospital,
Brooklyn.

Friday, January 28th. — Academy of Pathological Science :
Audubon Medical Society (annual) ; New York Clinical
Society ; Society of Alumni of Sloane Hospital for WomeiTT
Brooklyn Society of Internal Medicine; Hospital Grad-
uates' Club of Brooklyn (annual).

Died.

BoARDMAN. — In Boston Mass., on Tuesday, January 11th.
Dr. William E. Boardman, aged seventy-six years.

Caulkings. — In Hornell, N. Y., on Tuesday, January
4th, Dr. Frank L. Caulkings, aged seventy-three years.

De Lap. — In Gloucester, N, J., on Thursday, January
6th, Dr. W. L. De Lap, aged sixty-eight years.

FixLEY. — In Brooklyn, N. Y., on Wednesday, January
Sth, Dr. Eugene Francis Finley, aged fifty-two years.

Gordox. — In Los Angeles, Cal., on Wednesday, January
Sth, Dr. J. S. Gordon, aged sixty-six years.

Helme. — In Albany, N. Y., on Tuesday, January 4th, Dr.
Thomas Helme, of McKownville, aged fifty-three years.

Rowland. — In Cortland, N. Y., on Saturday, January
1st. Dr. Frank P. Howland, aged eighty years.

McFadden. — In Philadelphia, Pa., on Sunday, January
9tli, Dr. William McFadden, aged seventy-six years.

Murphy. — In Mobile, Ala., on Wednesday, January Sth,
Dr. Thomas Charles Murphy, aged seventy-seven years.

NoL.'VN. — In Philadelphia, Pa., on Wednesday, January
Sth, Dr. Edward James Nolan, aged seventy-four years.

O'Dea. — In Stapleton, S. I., on Wednesday, January
12th, Dr. James J. O'Dea, aged eighty-four years.

Rogers. — In Cascade, Wis., on Thursday, December 23rd,
Dr. A. C. Rogers, aged seventy-seven years.

Book Reviews

\'i<:xi-:ki-:ai. 1)isi<:ase.

Prevention of I'cnercal Disease. By Sir Archdall
Reii). K. H. E.. M.B., F. R. S. E. With an Introductorv
Chaptor l)y Sir Bryax Donkix, M. D, F. R. C. V.

*

It may be premised before entering into a con-
sideration of this hook that the author knows well
whereof he speaks. Sir Archdall Reid has had most
favorable opportunities for investigating and study-
ing venereal disease in all its phases and he is
excellently qualified to take the best advantage of
these opportunities. He is not only a scientific man
of the hrst rank, but is endowed also with sound
common sense, a quality not infrequently absent
from men of science. As witness of this combina-
tion of scientific and common sense, his book on
alcoholism may be referred to as the most able pre-
sentation of the subject ever given.

His work at Portsmouth, the British naval port
and a hot bed of venereal infection, has convinced
him that venereal disease is easily prevented, that
is, if proper and adequate preventive measures
are applied early enough, and his war experience
has taught him that such meastires are at hand and
indeed have been already practised on a large scale
in various parts f)f the world and always with suc-
cess. He therefore gives as his emphatic opinion
that the prevention of venereal disease is a certainty
in the near future and that with official help it w'ill
come quickly in Great Britain ; without such help
more slowly btit come it will. He further states,
what is obviously true, that it depends upon the
diffusion of a little ,simple knowledge of a kind that
spreads rapidly, and which once diffused is diffused
forever.

Conseqtiently, this book of Sir Archdall Reid
should give it a start with the public and should
aid in its diffusion immensely. Until the public is
educated as to the real state of affairs with regard
to venereal disease and the most effective means of
prevention, it is hopeless to expect much progress
in discussing the book. It shoitld be said at once,
that it has been written mainly to propagate the
views of the British Society for the I'revention of
Venereal Disease but also that the author has be-
come absolutely assured by a wide experience that
these views are based on a firm foundation. These
views are that reliable disinfectants shotdd be used
as promptly as possible after intercourse, that their
value is effective in proportion to the speed with
which they are used after the need for them has
arisen. According to Sir Archdall Reid, and his
testimony is tmdoubtedly reliable, many doctors
putting these principles into practice had reduced
the venereal disease, previously rife among their
charges, almost to the vanishing point. As the
author says, "obviously there tnust be something
peculiar in the methods that achieved success in the
midst of ])revailing failure."

The first cha])ter is taken up with impressing
upon the reader the urgency of the venereal problem
in Great Britain, '{'here is no time nor space here
to dwell long upon this aspect of the subject. In the
words of the author venereal diseases are the most
prevalent by far of all the more serious diseases.

There are few, if any, families of which some mem-
bers have not been infected. Together they con-
stitute a prolific, if not (juite the principal cause
of poverty, insanity, ])aralysis, blindness, heart dis-
ease, disfigurement, sterility, disablement and the
life of pain to which many women are condemned.
Our hospitals, asylums and homes for the broken
are crowded with their victims. All this is true with
respect to Great Britain and to all other countries
to a greater or less extent. It must always be borne
in mind that the venereal problem is an international
one.

The succeeding three chapters deal with the
psychological phase of the problem which provide
fascinating reading. Chapter IX in which Reid
describes his "campaign against venereal diseases
among troops in Portsmouth, who were all to a
greater or lesser extent birds of passage, is of quite
exceptional interest. The burden of this chapter
is that Reid by precept and practice held on to the
old saw that prevention is better than cure. "Dis-
infect, at once, at once," was his constant refrain.
As for the disinfectants to be used, it is stated that
ordinary antiseptics are .NU])erior to calomel if (juick
action be taken.

A goodly part of tliis book is devoted to a criti-
cism of the method of the British National Council
for Combating Venereal Disease and to British
official measures generally. The Council is averse-
to what may be termed direct prophylaxis, de-
claiming that the introduction of such a .scheme into
a civilian population would be tantamount to af-
fording opportunities for unrestrained vice. The
main points in the book before us are that the public
must be educated with respect to the venereal dis-
eases and the best means of prevention and it is
insisted that the most effective measures are dis-
infection as soon as possible after intercourse. To
.say that the book is well worth reading is faint
praise, to say that it ought to be read by every adult
would not be praising it too highly. Of course,
there will be many at variance with the views ex-
])ressed.

However, it should not be forgotten that Reid
has had a very wide practical experience with the
tenets he advances. He can bring strong clinical
evidence in sujiport of his contentions, which is
after all the su])reme test. As the venereal question
is international, it concerns America cjuite as much
as it does Great Britain, and, therefore, a book the
contents of which are founded upon the results of
experience, shottld be welcomed and studied in this
country.

Unless direct prophylaxis is com])rehended and
discussed by the medical profession and the public,
no decision can be made on its merits and draw-
backs. It may be the means of the salvation of the
race or it may be found to be comparatively useless
in civil life. In any event, it should be discussed and
understood, and not tabooed as a subject not fit to
speak of. Sir Archdall Reid's book presents the
(|uestion from the ])oint of view of prompt prophy-
laxis, with directness and lucidity greatly to be com-
mended, and certainly is of great educational value.

January 22, 1921.]

BOOK REl-IEirS.

167

NEUROPSYCHIATRY.

.Shell Shock and Other Nenropsychiatric Problems. Pre-
sented in 589 Case Histories from the War Literature,
1914-1918. By E. E. SouTii.ARn. M. D., Sc. D., Director
(1917-1918) U. S. Army Neuropsychiatric Training
School (Boston Unit) ; Late Major. Chemical Warfare
Service, U. S. Army ; Bullard Professor of Neuropathol-
ogy, Harvard Medical School ; Director, Massachusetts
State Psychiatric Institute of the ^Massachusetts Com-
mission on Mental Diseases. With a Bibliography by
Norman Fenton. S. B., A. ^L; Sergeant, Medical Corps,
U. S. Army (Assistant in Psychology to the Medical
Director, Base Hospital 117, A. E. F.) ; Late Intern in
Psychology, Psychopatliic Department, Boston State
Hospital; Assistant in Keconstruction, National Commit-
tee for Mental Hygiene. And an Introduction by Charles
K. Mills, M. D., LL.D.. Emeritus Professor of Neu-
rology, .University of Pennsvlvania. Illustrated. Bos-
ton : W. M. Leonard, Vm. Pp. vi-98i.

Southard's voluminous study of sliell shock forms
in some respects an outstanding- work. He has
spared no pains to glean his material from eminent
neuropsychiatrists who dealt at hrst hand with the.se
disorders arising during the war. There is not to
be found, therefore. an\- other such abundant
material in actual number of case histories. He has
also set forth in an unprejudiced manner all the pos-
sible symptoms that ])ecome manifest, with no
attempt dogmatically to place them under one or
another predetermined diagnosis. They are left for
future study from the several points of view they
suggest.

For the writer is openminded enough to act
upon the impression his researches make u]}on
him. He becomes more firmly convinced of the
wide range of possibilities in variety, in interre-
lation, in sequence of cause and elYect, which may
be subsumed under one such nonexplanatory term
as shell shock. He even welcomes the term for
its convenience to the lay mind, containing as it
does just enough indication of more definite factors
to turn attention to professional assistance. At
the same time he believes that it has by the time of
writing become a sufficiently denoting term to the
neuropsychiatrist to remind him that it serves as a
convenient cover for endless details of diagnosis
and treatment extending in every direction.

He presents a weiglit of evidence to show the
necessity of delimiting and differentiating the phe-
nomena appearing under it in order that syphilitic
disorders, toxic psychoses, epilepsies, dementia
prsecox, the cyclothymias, the psychoneuroses, shall
not pass undiscovered. Phenomena pertaining to
any of these at¥ections may already be present and
must not be taken as direct result of shell shock.
These affections may'^redispose to disturbance fol-
lowing actual shock, or they themselves may be
roused from latent to active form. All these facts
create cjuestions of importance from the medical,
the military, the legal point of view.

Thus shell shock comes to be recognized as onlv
a new term for an old state of things, a new pos-
sibility arising under special conditions wherein all
sorts of neuropsychopathic phenomena are possible.
Under these new conditions much has been learned.
Much more has presented itself as fertile material
for further consideration.

Southard lays stress upon the minute distinctidn
which has arisen largely from Bahinski's work.

between physiopathic and psychopathic di.sorders.
He still fails to discern that close relationship be-
tween the two, through unconscious i)sychic stimu-
lation of pliysiological paths and reaction in turn of
tlie physiological u])on the |)sychic. Tliere is also
the same old imenlightening use of such terms as
psychasthenia and the like, which cloaks the need
for this deeper i)enet ration into d\iiamic factors.
As a compendium of widely collected descriptive
material otTered as a stinuihis to further study, the
book remains as a monument of the indefatigable
energy and the alert mind of one whom the pro-
fession cannot forget.

VACCINATION.

/ 'itCi illation in the Tropics. By W. G. Kind. C. 1. E., Colonel,
I. M. S. (Retired), Late Sanitary Commissioner with the
(iovcrnment of Madras, and Superintendent (Jeiieral nf
\ accination and Inspector General of Civil Hosi)itals in
N'urina. Illustrated. London : Tropical Disease Kirreau.
1920. Pp. vi-64.

Inoculation, vaccination, smallpox, terms which
everyone thought they knew all about, are only the
doors to dee]i studies of bow they variously affect
men of different races, how they are aft'ected by
climate, the .safest methods of getting and conserv-
ing good strains of vaccine and the periodicity of
epidemics, all of which study advances us a long-
way since the days of 1902 w'ben French doctors
held vaccination parties and. with twenty or thirty
ladies assembled, walked around inoculating on
un.sterilized legs with an unsterilized instrument.

What complete mastery of all these aspects of
vaccination means, what conscientious research
involves, can he learned through W. ii. King's
book, written at the request of \^iscount Milner,
Secretary of State for the English Colonies, for
distrihution to the govemments of the tropical
African dependencies. He first deals with the sul)-
ject from a point of view which will rouse all men
— that is, the money loss caused by an epidemic.

One difficulty about the animal vaccine in tropical
climates is that tl-ie exaggerated conditions of
heat and alternate dry and moisture saturated
atniospheric stales demand close supervision by
responsible men giving their whole time : otherwise,
successful cultivation of vaccine ^will he ho])eless.
Suitable vaccine stations, food and quiet for the
animals, great care in transmission, are all neces-
sary. The influence of diet on the nature of vesicle
])roduction is also very great. The staff should be
well chosen, the .selection of calves most careful,
fust as the veterinarians have found neurasthenic
cows which needed a rest cure, so cheerful sur-
roundings are necessary for the anteiiioculated
calves, who are very susceptible to rougli treatment,
even loud voices.

The rejuvenation section shows the various
methods compared, and the factors in degeneration.
Tile ]ireservation of animal vaccine presents diffi-
culties that no doctor in the temperate zone can
'luite ajipreciale. The inclusion of Xoguclii's
method of purification of vaccine is a valuable
adjunct to the clearly put statements in this book
and tlie whole will be welcomed by the medical
-enlrio in opposing ihe advancement of the dreadful
(lisea>c.

168

BOOK REVIEWS.

[New V')rk

MeDICAI, JOIRX.VL.

MILITARY SPYING.

The Secret Corps. A Tale of Intelligence on All Fronts.
By Captain Ferdinand Tuohy. New York : Thomas
Seltzer, 1920. Pp. 289.

Spying and spy catching seemed a cotnparatively
simple matter in ancient times, but today science aids
both catclier and spy, and has created a hundred
ways of detection and escape which keep the in-
telligence departments of all nations unceasingly
on the alert. Away back we see Judith, "beautiful
in her countenance and witty in her words," calmly
going into the enemy's camp to beguile Holofernes,
and Joshua, falling a prey to the pretended ambas-
sadors who "came with old wine bottles, old and
rent and bound up ; with old shoes and clouted upon
their feet, and old garments, and the bread of their
provision dry and mouldy, saying, 'we be come
from a far country,' " whereas the rogues dwelt
quite near. The Hague law of those days must
have been compelling, for Joshua, having passed his
word to save them, simply detained them as hewers
of wood and drawers of water for the temple.

Of course, during the war it came to be a case
of being suspected of being suspected, even as hun-
dreds were executed during the French Revolution
for unintentionally doing slightly abnormal things.
This book will evoke gratitude and admiration for
its revelation of the espionage work done, and our
consequent safety. It would have been curious if,
for one hour, the whole mechanism, crossing, run-
ning parallel, submarine, miles high, winged, vocal,
written, signalled, could have stood out in relief, to
let us see the marvelous ingenuity displayed and
the risks run.

It is well pointed out how much power a queen
has. Even a foolish princess on the throne of a
foreign country is an agent who has access to
cabinet documents, and to cabinet councils ; who
can send the secrets of state to the land of her
fathers. In the late war, German or Austrian
women were on the thrones of Russia, Greece,
Sweden, Spain (Queen Mother), Rumania (Car-
men Sylva), and Bulgaria, while a German prince
consort ruled in Holland.

The Grecian queen, Sophia Dorothea, surrounded
herself with German women, kept Greece out of
war, and established a complete espionage bureau
behind the lines at Salonika, even through the lines.
The story of court intrigue at Athens is one of
the most amazing pictures of the whole war. It
was intrigue, corruption, and seduction in their most
outrageous forms.

The spy organizations had to be divided up into
zones, obviously necessary, if we consider even one
zone — the British, in France and Flanders with an
abnormal population due to many hundred thousand
refugees, Flemish, French, and Belgian, and added
to these three or four million regular inhabitants,
the British spy zone meant 800 communes, each
covering about five miles. The book abounds
with the unexpected. Once the truth was some-
times so obviously the truth that the Germans,
intercepting the message, concluded it was not the
truth or it would not have been sent, which was
exactly what the English thought they would do.
Again, on the second day of Loos, train after

train steamed up the German lines, twenty-five of
them, each train holding 800 men. The English
plans were remolded. It was faked "raihvay
activity" for the trains were empty! Two years
later, General Byng's November battle for Cambrai,
there was great enemy activity, hundreds upon
hundreds of lorries quite observable. Clearly the
enemy was being moved into a new reserve.
Headquarters was rung up. "Carry on," came the
answer. "They played this trick before. The lor-
ries are empty."
They were not !

The book keeps one all alert. A continued read-
ing will make a man involuntarily get up frotn his
chair very cautiously and cast a suspicious eye even
on his intimate associates and surroundings until
he remembers the world is at peace !

POTTERISM.

Potterism. By Rose Mac^ulay. New York : Boni & Live-
right, 1920. Pp. x-227.

Unconsciously the reader gathers in the opening
pages what Potterism is, but is rather relieved to
get a clear definition from the author on page 66 :

"Potterism has, for one of its surest bases, fear.
The other bases are ignorance, vulgarity, mental
laziness, sentimentality and greed. The ignorance
which does not know facts, the vulgarity which
cannot appreciate values ; the laziness which will not
try to learn either of those things ; the sentimentality
which, knowing neither, is stirred by the valueless
and the untrue ; the greed which grabs and exploits ;
the fear of public opinion, the fear of scandal, the
fear of independent thought, of loss of position, of
discomfort, of consequences, of truth."

There are only two characters who are untainted
by Potterism — Arthur Gideon, of Jewish extrac-
tion, editor of The Fact, and Katherine Varick, an
Oxford girl enjoying a chemical research scholar-
ship. So, saving these two, the world of this hook is
made up of the Potter twins, Jane and Johnnie, who
professedly hate Potterism but stealthily, even
openly, enjoy its fruits, Papa and Mama and Clare
Potter, a newspaper magnate, an author, and a
nonentity, their clergyman son, Frank, Hobart,
editor of a Potter paper, and Jake, a youfig West
End vicar of "moderately aristocratic lineage" but
antipotterist.

There is no subtle persuasion against Potterism
woven into the story. The characters are drawn in
a subcynical, sagacious, humorous fashion, which
amuse, but makes readers flinch a little. They seem
to be getting too intimate a view of their friends.
It would have been well if a deeper discernment of
all that is noble and true had been joined to the
writer's keen insight into human nature and touched
her strong desire for truth. In describing Gideon
after he has (supposedly) knocked Hobart down-
stairs and killed him, she voices the old surprised
inquiry as to whether the good man can suddenly
or deliberately walk in miry ways, whether the low-
minded and repulsive man can produce valor and
virtue from the empty pockets of his shabby, filthy
garments, for many disbelieve this, despite the
annals of asylum and prison. If Rose Macaulay
can draw such clever realistic pictures of men as

January 22, 1921.]

BOOK REVIEWS.

169

tlie)- are, it is a safe prediction to say her next work
will contain a few men as they might be, just to
tempt our dusty souls into more breezy, sunlit ways.

Some little, well, not errors, but ungraceful
expressing, will not appear in her second book, e. g. :
. . . one doesn't know enough ; one hasn't learnt
or lived enough to be first hand ; and one lacks
selfconfidence. But by five or six and twenty
one should have left that behind. One should know
what one tliinks, and what one means. . . .

"A woman can be a man's friend all their lives,
but a man, in nine cases out of ten, will either get
tired of it or want more."

There was no weekly which caused Edward VII
to chuckle more heartily than Modern Society, a
paper which consistently attacked the rich, routed
out all scandals in high life, and referred to Queen
\'ictoria as Mrs. Little Britain and the Heir as
"Bertie," and it is just possible that smug Potter-
ites, w'ho live in words not deeds, and are yet not
too selfsatisfied, will enjoy and profit from tliis
book. Nearly everyone will be glad to have a name
given to the selfdeception whicli blindly applauds
that which it uneasily condemns, unconsciously
echoing the wish :

. . . . that there might in England be

A duty on Hypocrisy,

A tax on humbug, an excise

On solemn plausibilities.

<^

New Publications Received.

\We publish full lists of books received, but we acknowl-
edge no obligation to review them all. Nevertheless, so
far as space permits, we review those in which we think
our readers are likely to be interested.]

SAN CRISTOBAL DE LA HABANA. By JoSEPH HeRGESHEIMER.

New York : Alfred A. Knopf, 1920. Pp. 255.

TWENTV-SEVEXTH .^XXUAL REPORT OF THE MAX.\GERS .AND

OFFICERS OF THE CR.\iG COLONY. Craig Colony Press, 1920.
Pp. 84.

THE devil's paw. Bv E. Phillips Oppenheim. With
Frontispiece by H. Weston Taylor. Boston : Little, Brown
& Co., 1920. Pp. 295.

THE privilege OF PAIN. By Mrs. Leo Everett. Intro-
duction by Kate Douglass Wiggin. Boston : Small, May-
nard & Co., 1920. Pp. 105.

the spoils of the strong. By Ele.\nor T.\lbot Kin-
kead (Mrs. Thompson Short). New York: The James A.
McCann Company, 1920. Pp. 308.

THE human atmosphere. By Walter J. Kilner, B. A.,
M. B. (Cantab.), M. R. C. P., etc., Late Electrician to St.
Thomas's Hospital, London. With Sixty-four Illustrations.
London : Kegan Paul, Trench, Trubner & Co., Ltd., 1920,
and New York : E. P. Button & Co., 1920. Pp. vii-300.

AIDS TO osteology. By Phiup Turner, B. Sc., M. B.,
M.S. (Lond.), F. R. C. S., Assistant Surgeon, Guy's Hos-
pital ; Teacher of Operative Surgery in the Medical School.
Second Edition. New York: William Wood & Co., 1920.
Pp. 187.

DREAM psychology. Psychoanalysis for Beginners.
By Prof. Dr. Sigmund Freud. Authorized English Trans-
lation by M. D. Eder. With an Introduction by Andre
Tridon, Author of Psychoanalysis, Its History, Theory,
and Practice, Psychoanalysis and Behaznor, and Psycho-
analysts, Sleep, and Dreams. New York: The James A.
McCann Company, 1920. Pp. xi-237.

ANNUAL report OF THE SURGEON GENERAL, U. S. NAVY,

Chief of the Bureau of Medicine and Surgery, to the Sec-
retary of the Navy for the Fiscal Year 1920. Wash-
ington: Government Printing Office, 1920. Pp. 326.

collected papers of the mayo clinic, ROCHESTER, MIN-
NESOTA. Edited by Mrs. M. H. Mellish. Volume XI, 1919.
Published September, 1920. Philadelphia and London :
W. B. Saunders Company, 1920. Pp. 1331.

SLEEP WALKING AND MOON WALKING. .\ Mcdicoliterary
Study. By Dr. J. Sadger, Vienna. Translated by Louise
Brink. Nervous and Mental Disease Monograph Scries
No. 31. New York and Washington: Nervous and Mental
Disease Publishing Company, 1920. Pp. x-140.

THE SOCIAL DISEASES. Tubcfculosis, Syphilis, Alcoholism,
Sterility. By Dr. J. Hericourt. Translated, and With a
Final Chapter, by Bernard Miall. London: George Rout-
ledge & Sons, Ltd.; New York: E. P. Dutton & Co., 1920.
Pp. viii-246.

PARACELSUS. His Personality and Influence as Physician,
Chemist and Reformer. By John Ma.xson Stillman,
Professor of Chemistry Emeritus, Stanford University.
Chicago and London : The Open Court Publishing Com-
pany. 1920. Pp. viii-184.

anesthetics. Their Uses and Administration. By
Dudley Wilmot Buxton, M.D., B.S., Member of the
Royal College of Physicians; Sometime President of the
Society of Anaesthetists ; Member of University College,
etc. Sixth Edition. Philadelphia : P. Blakiston's Son &
Company, 1920. Pp. xvi-548.

THE MAJOR symptoms OF HYSTERIA. Fifteen Lcctures
given in the Medical School of Harvard University. By
Pierre Janet, Ph.D., M.D., Member of the Institute of
France, Professor of Psychology in the College de France.
Second Edition with New Matter. New York : The Mac-
millan Company, 1920. Pp. xxiii-34S.

medical GYMNASTICS IN MEDICINE AND SURGERY. By E.

Bellis Clayton, M. B., B.C. (Cantab.), Director of the
Physiotherapeutic Department, and in Charge of the Mas-
sage and Electrical School, King's College Hospital,
London. New York : Longmans, Green & Co. ; London :
Edward Arnold, 1920. Pp. viii-159.

A NATURALIST ON LAKE VICTORIA. With an AcCOUnt of

Sleeping Sickness and the Tse-Tse Fly. By G. D. Hale
Carpenter, D. M., B. Ch. (Oxon.) Uganda Medical Ser-
vice ; Fellow of the Linnaen, Entomological, and Zoological
Societies of London. With Two Colored Plates, a Map,
Charts, and Eighty-seven Illustrations. New York : E. P.
Dutton & Co., 1920. Pp. xxiv-333.

INTRODUCTION TO GENERAL CHEMISTRY. An Exposition of
the Principles of Modern Chemistry. By H. Copaux,
Professor of Mineral Chemistry at the School of Industrial
Physics and Chemistry of the City of Paris. Translated by
Henry Leffmann, A. M., M. D., Member of the American
Chemical Society and of the (British) Society of Public
Analyses. With Thirty Illustrations. Philadelphia : P.
Blakiston's Son & Co., 1920. Pp. x-195.

THE PRACTICAL MEDICINE SERIES. Comprising Eight Vol-
umes on the Year's Progress in Medicine and Surgery.
Under the General Editorial Charge of Charles L. Mix,
A. M., M. D., Professor of Physical Diagnosis in the
Northwestern University Medical School Volume III :
The Eye, Ear, Nose, and Throat. Edited by Casey A.
Wood, C. M., M. D., D. C. L. ; Albert H. Andrews, M. D.,
and George E. Shambaugh, M. D. Series 1920. Chicago:
The Year Book Publishers, 1920. Pp. 381.

THE PRACTICAL MEDICINE SERIES. Comprising Eight Vol-
umes on the Year's Progress in Medicine and Surgery.
Under the General Editorial Charge of Charles L. Mix,
A. M., M. D., Professor of Physical Diagnosis in the
Northwestern University Medical School. Volume II :'
General Surgery. Edited by .\lbert J. Ochsner, M. D.,
F. R. M. S., LL. D., F. A. C. S., Major, M. R. C, U. S. Army ;
Surgeon in Chief, Augustana and St. Mary's of Nazareth
Hospitals ; Professor of Surgery in the ^ledical Depart-
ment of the State University of Illinois. Series 1920.
Chicago : The Year Book Publishers, 1920. Pp. 620.

Practical Therapeutics and Preventive Medicine

A Compendium of Treatment and Prophylaxis, Original and Adapted

Pernicious Anemia. — James G. Carr {American
Journal of the Medical Sciences, Xovember, 1920).
in a study of 148 cases, finds thai the clinical com-
plex known as pernicious anemia presents certain
characteristic blood findings, particularly the